Provider Demographics
NPI:1346207149
Name:SOUTHDALE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:SOUTHDALE INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUNKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-927-7079
Mailing Address - Street 1:6545 FRANCE AVENUE SOUTH
Mailing Address - Street 2:SUITE 510
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-927-7079
Mailing Address - Fax:952-920-9758
Practice Address - Street 1:6545 FRANCE AVENUE SOUTH
Practice Address - Street 2:SUITE 510
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-927-7079
Practice Address - Fax:952-920-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC00361Medicare ID - Type UnspecifiedMEDICARE PRACTICE ID