Provider Demographics
NPI:1013056969
Name:INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:320-229-1500
Mailing Address - Street 1:2301 CONNECTICUT AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2474
Mailing Address - Country:US
Mailing Address - Phone:320-229-1500
Mailing Address - Fax:320-229-1505
Practice Address - Street 1:2301 CONNECTICUT AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2474
Practice Address - Country:US
Practice Address - Phone:320-229-1500
Practice Address - Fax:320-229-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41961208100000X, 208VP0014X, 261QP2000X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410645800Medicaid
MNC03449OtherMEDICARE PTAN
MNH31283Medicare UPIN
MN410645800Medicaid