Provider Demographics
NPI:1225158520
Name:CHILD AND TEEN MEDICAL CENTER
Entity Type:Organization
Organization Name:CHILD AND TEEN MEDICAL CENTER
Other - Org Name:FRIDLEY CHILDREN'S AND TEENAGERS' MEDICAL CENTER PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:763-333-7755
Mailing Address - Street 1:11107 ULYSSES ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4184
Mailing Address - Country:US
Mailing Address - Phone:763-333-7733
Mailing Address - Fax:763-333-7711
Practice Address - Street 1:11107 ULYSSES ST NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4184
Practice Address - Country:US
Practice Address - Phone:763-333-7733
Practice Address - Fax:763-333-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty