Provider Demographics
NPI:1790092815
Name:PARK NICOLLET CLINIC
Entity Type:Organization
Organization Name:PARK NICOLLET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-993-1600
Mailing Address - Street 1:9827 MAPLE GROVE PKWY N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4491
Mailing Address - Country:US
Mailing Address - Phone:952-993-5900
Mailing Address - Fax:
Practice Address - Street 1:9827 MAPLE GROVE PKWY N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4491
Practice Address - Country:US
Practice Address - Phone:952-993-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8585282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital