Provider Demographics
NPI:1174684336
Name:NORTHPORT MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:NORTHPORT MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-533-8666
Mailing Address - Street 1:5415 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3359
Mailing Address - Country:US
Mailing Address - Phone:763-533-8666
Mailing Address - Fax:763-533-8711
Practice Address - Street 1:5415 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3359
Practice Address - Country:US
Practice Address - Phone:763-533-8666
Practice Address - Fax:763-533-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0527880001Medicare NSC
MNC00127Medicare UPIN