Provider Demographics
NPI:1417251935
Name:LTC PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:LTC PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-479-4261
Mailing Address - Street 1:7801 E BUSH LAKE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3113
Mailing Address - Country:US
Mailing Address - Phone:952-479-4261
Mailing Address - Fax:866-991-7241
Practice Address - Street 1:7801 E BUSH LAKE RD STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-3113
Practice Address - Country:US
Practice Address - Phone:952-479-4261
Practice Address - Fax:866-991-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20837207P00000X, 207Q00000X
MN42701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629038377OtherMEDICARE NPI
MN1801814504OtherMEDICARE NPI
MNH23581Medicare UPIN