Provider Demographics
NPI:1437313434
Name:CENTRAL MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:CENTRAL MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARALEGAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-922-7573
Mailing Address - Street 1:393 N DUNLAP STREET
Mailing Address - Street 2:SUITE LL34
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-644-6002
Mailing Address - Fax:651-644-2048
Practice Address - Street 1:393 N DUNLAP STREET
Practice Address - Street 2:SUITE LL34
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-644-6002
Practice Address - Fax:651-644-2048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37899208VP0000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2168900Medicaid
MNF94006Medicare PIN