Provider Demographics
NPI:1659323459
Name:NEIGHBORHOOD HEALTHSOURCE
Entity Type:Organization
Organization Name:NEIGHBORHOOD HEALTHSOURCE
Other - Org Name:NORTH METRO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:KNUTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-287-2428
Mailing Address - Street 1:2301 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:612-588-9411
Mailing Address - Fax:612-781-3837
Practice Address - Street 1:10081 DOGWOOD ST. NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448
Practice Address - Country:US
Practice Address - Phone:612-588-9411
Practice Address - Fax:763-783-7944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEIGHBORHOOD HEALTHSOURCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN312S6N0OtherBCBS
MN463988000Medicaid
MN463988000Medicaid