Provider Demographics
NPI:1790772259
Name:GATEWAY FAMILY HEALTH CLINIC, LTD.
Entity Type:Organization
Organization Name:GATEWAY FAMILY HEALTH CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-485-4491
Mailing Address - Street 1:4570 CTY HWY 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9401
Mailing Address - Country:US
Mailing Address - Phone:218-485-4491
Mailing Address - Fax:218-485-4724
Practice Address - Street 1:204 LUNDORFF DR
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5051
Practice Address - Country:US
Practice Address - Phone:320-245-2250
Practice Address - Fax:320-245-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48729207Q00000X
MN41745207Q00000X
MN47303207Q00000X
MN34715207Q00000X
MN46671207Q00000X
MN49738207Q00000X
MN54207207Q00000X
MN43633207R00000X, 208000000X
MN43634207R00000X, 208000000X
MN11706363A00000X
MNR 120278-4363L00000X
MNR 147424-0363L00000X
MNR 137363-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN243859Medicare Oscar/Certification
MN0898510005Medicare NSC