Provider Demographics
NPI:1760144679
Name:MINNESOTA PERSONALIZED MEDICINE LLC
Entity Type:Organization
Organization Name:MINNESOTA PERSONALIZED MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PLOTNIKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-345-5029
Mailing Address - Street 1:1409 WILLOW ST STE 501
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3288
Mailing Address - Country:US
Mailing Address - Phone:612-345-5029
Mailing Address - Fax:612-392-3957
Practice Address - Street 1:1409 WILLOW ST STE 501
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3288
Practice Address - Country:US
Practice Address - Phone:612-345-5029
Practice Address - Fax:612-392-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN34265OtherMEDICAL LICENSE
MN47498OtherMEDICAL LICENSE
MN43318OtherMEDICAL LICENSE