Provider Demographics
NPI:1932316916
Name:PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Entity Type:Organization
Organization Name:PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-256-6706
Mailing Address - Street 1:1804 7TH ST W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2300
Mailing Address - Country:US
Mailing Address - Phone:651-227-7806
Mailing Address - Fax:651-256-6766
Practice Address - Street 1:1804 7TH ST W
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2300
Practice Address - Country:US
Practice Address - Phone:651-227-7806
Practice Address - Fax:651-256-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN154261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1083694046Medicaid
MN1245210210Medicaid
MN1912987900Medicaid
MN1104806165Medicaid
MN1245210095Medicaid
MN1477870921Medicaid
MN1881057065Medicaid
MN1497735419Medicaid
MN1861558835Medicaid
MN1386991339Medicaid