Provider Demographics
NPI:1457448094
Name:PIPESTONE FAMILY CLINIC
Entity Type:Organization
Organization Name:PIPESTONE FAMILY CLINIC
Other - Org Name:JASPER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-825-5811
Mailing Address - Street 1:920 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-1455
Mailing Address - Country:US
Mailing Address - Phone:507-825-5700
Mailing Address - Fax:507-825-4752
Practice Address - Street 1:120 SHERMAN AVE N
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:MN
Practice Address - Zip Code:56144-1114
Practice Address - Country:US
Practice Address - Phone:507-348-3071
Practice Address - Fax:507-348-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2569527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN149723500Medicaid
MN149723500Medicaid