Provider Demographics
NPI:1477680718
Name:SOUTHDALE ALLERGY AND ASTHMA CLINIC, LLC
Entity Type:Organization
Organization Name:SOUTHDALE ALLERGY AND ASTHMA CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHINDELDECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-926-7630
Mailing Address - Street 1:4010 W 65TH ST
Mailing Address - Street 2:#221
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1721
Mailing Address - Country:US
Mailing Address - Phone:952-926-7630
Mailing Address - Fax:952-926-2116
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:#221
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55435-1721
Practice Address - Country:US
Practice Address - Phone:952-926-7630
Practice Address - Fax:952-926-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23905207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95455Medicare UPIN