Provider Demographics
NPI:1750655882
Name:MEDICA HEALTH MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MEDICA HEALTH MANAGEMENT, LLC
Other - Org Name:INTEGRATED CARE BY MEDICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT GOV. PROGRAMS
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-992-3977
Mailing Address - Street 1:401 CARLSON PKWY
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5359
Mailing Address - Country:US
Mailing Address - Phone:952-992-2000
Mailing Address - Fax:952-992-8665
Practice Address - Street 1:401 CARLSON PKWY
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5359
Practice Address - Country:US
Practice Address - Phone:952-992-2000
Practice Address - Fax:952-992-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21268142363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty