Provider Demographics
NPI:1326301532
Name:MNMIDWIFE
Entity Type:Organization
Organization Name:MNMIDWIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIDWIFE
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JO ANNE
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:TM
Authorized Official - Phone:651-329-4514
Mailing Address - Street 1:16930 CHISHOLM ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4923
Mailing Address - Country:US
Mailing Address - Phone:651-329-4514
Mailing Address - Fax:
Practice Address - Street 1:16930 CHISHOLM ST NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-4923
Practice Address - Country:US
Practice Address - Phone:651-329-4514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty