Provider Demographics
NPI:1891058384
Name:PROACTIVE HEALTHCARE
Entity Type:Organization
Organization Name:PROACTIVE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-778-0080
Mailing Address - Street 1:101 5TH ST E
Mailing Address - Street 2:SUITE 227
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1898
Mailing Address - Country:US
Mailing Address - Phone:651-778-0080
Mailing Address - Fax:651-778-0195
Practice Address - Street 1:101 5TH ST E
Practice Address - Street 2:SUITE 227
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1898
Practice Address - Country:US
Practice Address - Phone:651-778-0080
Practice Address - Fax:651-778-0195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41988208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1891058384Medicaid
MN1891058384Medicare UPIN
MN6700580001Medicare NSC