Provider Demographics
NPI:1891031209
Name:MEDICAL ADDICTION TREATMENT CLINIC
Entity Type:Organization
Organization Name:MEDICAL ADDICTION TREATMENT CLINIC
Other - Org Name:SAGE PRAIRIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PYLKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-435-7380
Mailing Address - Street 1:3805 WASHINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-2141
Mailing Address - Country:US
Mailing Address - Phone:612-887-6282
Mailing Address - Fax:612-437-4992
Practice Address - Street 1:3805 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-2141
Practice Address - Country:US
Practice Address - Phone:612-887-6282
Practice Address - Fax:612-437-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52519207RA0401X
261Q00000X, 363LP0808X
MN12684363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty