Provider Demographics
NPI:1619413655
Name:SHINGLE CREEK MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SHINGLE CREEK MEDICAL GROUP, LLC
Other - Org Name:DISC CENTERS OF AMERICA BROOKLYN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STADTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-244-8021
Mailing Address - Street 1:2781 FREEWAY BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1765
Mailing Address - Country:US
Mailing Address - Phone:763-244-8022
Mailing Address - Fax:
Practice Address - Street 1:2781 FREEWAY BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1753
Practice Address - Country:US
Practice Address - Phone:763-244-8020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-14
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty