Provider Demographics
NPI:1831100072
Name:EAST METRO FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:EAST METRO FAMILY PRACTICE PA
Other - Org Name:EAST METRO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERRISFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-772-1572
Mailing Address - Street 1:2025 SLOAN PLACE
Mailing Address - Street 2:SUITE 35
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:2025 SLOAN PLACE
Practice Address - Street 2:SUITE 35
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117
Practice Address - Country:US
Practice Address - Phone:651-772-1572
Practice Address - Fax:651-772-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C01836Medicare ID - Type Unspecified
C01827Medicare ID - Type Unspecified
C01826Medicare ID - Type Unspecified
C01840Medicare ID - Type Unspecified
C01833Medicare ID - Type Unspecified
C02624Medicare ID - Type Unspecified