Provider Demographics
NPI:1447409834
Name:MINNESOTA ONCOLOGY HEMATOLOGY, PA
Entity Type:Organization
Organization Name:MINNESOTA ONCOLOGY HEMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-863-3961
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 110N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-602-5335
Mailing Address - Fax:
Practice Address - Street 1:3960 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2569
Practice Address - Country:US
Practice Address - Phone:612-863-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN896027500Medicaid
MN8T400MIOtherBLUE CROSS BLUE SHIELD OF MINNESOTA
MN896027500Medicaid