Provider Demographics
NPI:1902836133
Name:MIDWEST SPINE & BRAIN INSTITUTE, L.L.C.
Entity Type:Organization
Organization Name:MIDWEST SPINE & BRAIN INSTITUTE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MHA, CMPE
Authorized Official - Phone:651-430-3800
Mailing Address - Street 1:1950 NORTHWESTERN AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7615
Mailing Address - Country:US
Mailing Address - Phone:651-430-3800
Mailing Address - Fax:651-430-3827
Practice Address - Street 1:1950 NORTHWESTERN AVE S STE 102
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-7615
Practice Address - Country:US
Practice Address - Phone:651-430-3800
Practice Address - Fax:651-430-3827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2019-03-15
Deactivation Date:2018-09-12
Deactivation Code:
Reactivation Date:2018-10-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115117OtherUCARE
MN1M559MIOtherBLUE CROSS & BLUE SHIELD
WI32851500Medicaid
MNHP10969OtherHEALTHPARTNERS
MNN004668OtherCHAMPUS
MN0900009OtherMEDICA
MN620529100Medicaid
MN96425OtherPREFERRED ONE
MN1M559MIOtherBLUE CROSS & BLUE SHIELD
MNHP10969OtherHEALTHPARTNERS
MN96425OtherPREFERRED ONE
WI32851500Medicaid