Provider Demographics
NPI:1609995877
Name:NORTHWEST SPINE AND PAIN CENTER OF ST. MICHAEL, PA
Entity Type:Organization
Organization Name:NORTHWEST SPINE AND PAIN CENTER OF ST. MICHAEL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:MATTILA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-497-0899
Mailing Address - Street 1:1 CENTRAL AVE W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4591
Mailing Address - Country:US
Mailing Address - Phone:763-497-0899
Mailing Address - Fax:763-497-4035
Practice Address - Street 1:1 CENTRAL AVE W
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4591
Practice Address - Country:US
Practice Address - Phone:763-497-0899
Practice Address - Fax:763-497-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306903299OtherINDIVIDUAL NPI
MN350003850Medicare UPIN