Provider Demographics
NPI:1316043425
Name:FONG MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:FONG MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:TAN
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-731-3664
Mailing Address - Street 1:105 NEW ENGLAND PL
Mailing Address - Street 2:SUITE 220
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5783
Mailing Address - Country:US
Mailing Address - Phone:651-731-3664
Mailing Address - Fax:651-430-9981
Practice Address - Street 1:105 NEW ENGLAND PL
Practice Address - Street 2:SUITE 220
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5783
Practice Address - Country:US
Practice Address - Phone:651-731-3664
Practice Address - Fax:651-430-9981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39331261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO3675Medicare ID - Type UnspecifiedMEDICARE GROUP