Provider Demographics
NPI:1255300984
Name:MINNESOTA PAIN CENTER
Entity Type:Organization
Organization Name:MINNESOTA PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:YUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-731-0707
Mailing Address - Street 1:574 PRAIRIE CENTER DR
Mailing Address - Street 2:#135-310
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7930
Mailing Address - Country:US
Mailing Address - Phone:952-995-0151
Mailing Address - Fax:651-739-1674
Practice Address - Street 1:225 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 122
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2072
Practice Address - Country:US
Practice Address - Phone:651-731-0707
Practice Address - Fax:651-739-1674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1345207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN474213200Medicaid
MN474213200Medicaid