Provider Demographics
NPI:1760651038
Name:NORTH SUBURBAN HEALTHCARE PA
Entity Type:Organization
Organization Name:NORTH SUBURBAN HEALTHCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:TOLLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-754-2573
Mailing Address - Street 1:8171 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1865
Mailing Address - Country:US
Mailing Address - Phone:763-754-2573
Mailing Address - Fax:763-754-0128
Practice Address - Street 1:8171 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1865
Practice Address - Country:US
Practice Address - Phone:763-754-2573
Practice Address - Fax:763-754-0128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2478261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty