Provider Demographics
NPI:1376760777
Name:IVANHOE MEDICAL CENTER
Entity Type:Organization
Organization Name:IVANHOE MEDICAL CENTER
Other - Org Name:HENDRICKS CLINIC, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TABB
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:507-275-2295
Mailing Address - Street 1:366 E GEORGE ST
Mailing Address - Street 2:PO BOX 43
Mailing Address - City:IVANHOE
Mailing Address - State:MN
Mailing Address - Zip Code:56142-9707
Mailing Address - Country:US
Mailing Address - Phone:507-694-1100
Mailing Address - Fax:
Practice Address - Street 1:366 E GEORGE ST
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:MN
Practice Address - Zip Code:56142-9707
Practice Address - Country:US
Practice Address - Phone:507-694-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HENDRICKS CLINIC P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1757969261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN232816000Medicaid
MNC07204Medicare ID - Type Unspecified