Provider Demographics
NPI:1225703705
Name:MILES MED MANAGEMENT SERVICE CORPORATION
Entity Type:Organization
Organization Name:MILES MED MANAGEMENT SERVICE CORPORATION
Other - Org Name:MILES MED MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:APNP
Authorized Official - Phone:612-708-7562
Mailing Address - Street 1:4301 ELLIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3156
Mailing Address - Country:US
Mailing Address - Phone:612-708-7562
Mailing Address - Fax:507-738-1963
Practice Address - Street 1:5775 WAYZATA BLVD STE 767
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1222
Practice Address - Country:US
Practice Address - Phone:612-708-7562
Practice Address - Fax:507-738-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1225703705Medicaid
MN1093741886Medicaid