Provider Demographics
NPI:1174836597
Name:LITTLE CANADA MEDICAL CLINIC
Entity Type:Organization
Organization Name:LITTLE CANADA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ALLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-481-1119
Mailing Address - Street 1:75 LITTLE CANADA RD W
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1362
Mailing Address - Country:US
Mailing Address - Phone:651-481-1119
Mailing Address - Fax:651-481-1476
Practice Address - Street 1:75 LITTLE CANADA RD W
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1362
Practice Address - Country:US
Practice Address - Phone:651-481-1119
Practice Address - Fax:651-481-1476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20780261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND80937OtherUPIN
MN0123164OtherMEDICA
MN263273000Medicaid
MN20504LIOtherBLUE CROSS BLUE SHEILD
MN20504LIOtherBLUE CROSS BLUE SHEILD