Provider Demographics
NPI:1235381476
Name:HOMEOPATHIC MEDICAL CLINIC
Entity Type:Organization
Organization Name:HOMEOPATHIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:I
Authorized Official - Last Name:MIRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-933-8900
Mailing Address - Street 1:4201 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4728
Mailing Address - Country:US
Mailing Address - Phone:952-933-8900
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:4201 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4728
Practice Address - Country:US
Practice Address - Phone:952-933-8900
Practice Address - Fax:952-945-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2002688Medicaid
MNES0672Medicare UPIN