Provider Demographics
NPI:1821250549
Name:CROMWELL MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:CROMWELL MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BODE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-485-8123
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:MN
Mailing Address - Zip Code:55726-0116
Mailing Address - Country:US
Mailing Address - Phone:218-485-8123
Mailing Address - Fax:218-644-3811
Practice Address - Street 1:5568 CLARK AVE STE 1
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:MN
Practice Address - Zip Code:55726-5004
Practice Address - Country:US
Practice Address - Phone:218-644-3811
Practice Address - Fax:218-644-3813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care