Provider Demographics
NPI:1891055851
Name:ADVANCED SPINE AND PAIN CLINICS OF MINNESOTA LLC
Entity Type:Organization
Organization Name:ADVANCED SPINE AND PAIN CLINICS OF MINNESOTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:THORSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-207-7463
Mailing Address - Street 1:2801 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2125
Mailing Address - Country:US
Mailing Address - Phone:612-207-7463
Mailing Address - Fax:952-831-0276
Practice Address - Street 1:2801 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2125
Practice Address - Country:US
Practice Address - Phone:612-207-7463
Practice Address - Fax:612-315-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN530615900Medicaid
MN250013662Medicare PIN