Provider Demographics
NPI:1851314868
Name:MILLENNIUM NEUROSURGERY, PA
Entity Type:Organization
Organization Name:MILLENNIUM NEUROSURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHUDHIPHORN
Authorized Official - Middle Name:
Authorized Official - Last Name:THIENPRASIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-748-1461
Mailing Address - Street 1:1675 BEAM AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1172
Mailing Address - Country:US
Mailing Address - Phone:651-748-1461
Mailing Address - Fax:
Practice Address - Street 1:1675 BEAM AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1172
Practice Address - Country:US
Practice Address - Phone:651-748-1461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCN3928OtherRAILROAD MEDICARE
MNC02476Medicare ID - Type Unspecified