Provider Demographics
NPI:1558421404
Name:MINNESOTA STATE COLLEGES & UNIVERSITIES
Entity Type:Organization
Organization Name:MINNESOTA STATE COLLEGES & UNIVERSITIES
Other - Org Name:MSUM SPEECH LANGUAGE AND HEARING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:218-477-2393
Mailing Address - Street 1:1104 7TH AVE SOUTH
Mailing Address - Street 2:MSUM BOX 119
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56563-0001
Mailing Address - Country:US
Mailing Address - Phone:218-477-2330
Mailing Address - Fax:218-477-4392
Practice Address - Street 1:1104 7TH AVE SOUTH
Practice Address - Street 2:MSUM BOX 119
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563-0001
Practice Address - Country:US
Practice Address - Phone:218-477-2330
Practice Address - Fax:218-477-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52B45MOOtherMN BCBS
ND51661Medicaid