Provider Demographics
NPI:1629857222
Name:OUR LADY OF PEACE
Entity Type:Organization
Organization Name:OUR LADY OF PEACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-789-5031
Mailing Address - Street 1:2076 SAINT ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4543
Mailing Address - Country:US
Mailing Address - Phone:651-789-5031
Mailing Address - Fax:
Practice Address - Street 1:2076 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4543
Practice Address - Country:US
Practice Address - Phone:651-789-5031
Practice Address - Fax:651-789-0078
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF PEACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty