Provider Demographics
NPI:1922586270
Name:MBH-MN MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:MBH-MN MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BUD
Authorized Official - Middle Name:
Authorized Official - Last Name:LILE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-232-7558
Mailing Address - Street 1:550 MAIN ST # 190
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3271
Mailing Address - Country:US
Mailing Address - Phone:612-454-2046
Mailing Address - Fax:
Practice Address - Street 1:550 MAIN ST STE 260
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3273
Practice Address - Country:US
Practice Address - Phone:612-326-7558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherEIN NUMBER