Provider Demographics
NPI:1275894982
Name:CHILDREN'S CLINIC NETWORK
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC NETWORK
Other - Org Name:CHILDREN'S ENT AND FACIAL PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORELICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-813-8031
Mailing Address - Street 1:5901 LINCOLN DRIVE, CBC-2-REV/PE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-1611
Mailing Address - Country:US
Mailing Address - Phone:952-992-5398
Mailing Address - Fax:952-992-6917
Practice Address - Street 1:2525 CHICAGO AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty