Provider Demographics
NPI:1275534612
Name:NORTHERN OB GYN ASSOCIATES PC
Entity Type:Organization
Organization Name:NORTHERN OB GYN ASSOCIATES PC
Other - Org Name:NORTHERN OB/GYN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:WUST
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:763-427-8500
Mailing Address - Street 1:SDS 12 2503
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-2503
Mailing Address - Country:US
Mailing Address - Phone:763-427-8500
Mailing Address - Fax:763-427-8505
Practice Address - Street 1:3875 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2518
Practice Address - Country:US
Practice Address - Phone:763-427-8500
Practice Address - Fax:763-427-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN987940000Medicaid
MNCO3860Medicare ID - Type Unspecified