Provider Demographics
NPI:1942384193
Name:UNITED FAMILY PRACTICE HEALTH CENTER
Entity Type:Organization
Organization Name:UNITED FAMILY PRACTICE HEALTH CENTER
Other - Org Name:UNITED FAMILY PRACTICE HEALTH CENTER SIBLEY MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:NYAKUNDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-241-1084
Mailing Address - Street 1:1026 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3828
Mailing Address - Country:US
Mailing Address - Phone:651-241-1000
Mailing Address - Fax:
Practice Address - Street 1:1307 MAYNARD DR W
Practice Address - Street 2:SUITE 13
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2930
Practice Address - Country:US
Practice Address - Phone:651-699-2093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNA398OtherPREFERRED ONE
MNDB2459OtherRAILROAD MEDICARE
MN164690OtherUCARE
MN282M2UNOtherBLUE CROSS
MN697442000Medicaid
MN282M2UNOtherBLUE CROSS
MN164690OtherUCARE
MNC03533Medicare ID - Type UnspecifiedWPS
MN697442000Medicaid