Provider Demographics
NPI:1518187434
Name:MAPLE MEDICAL CENTER
Entity Type:Organization
Organization Name:MAPLE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-843-4333
Mailing Address - Street 1:9825 HOSPITAL DRIVE, #105
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-420-0580
Mailing Address - Fax:763-420-0581
Practice Address - Street 1:7261 OHMS LN
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2148
Practice Address - Country:US
Practice Address - Phone:952-843-4333
Practice Address - Fax:952-843-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04634Medicare UPIN