Provider Demographics
NPI:1760949168
Name:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Entity Type:Organization
Organization Name:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Other - Org Name:IHB MINNEHAHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-721-9800
Mailing Address - Street 1:1315 E 24TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3959
Mailing Address - Country:US
Mailing Address - Phone:612-721-9830
Mailing Address - Fax:612-721-7870
Practice Address - Street 1:2101 MINNEHAHA AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3107
Practice Address - Country:US
Practice Address - Phone:612-721-9800
Practice Address - Fax:612-721-7870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-22
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1811999162Medicaid