Provider Demographics
NPI:1184796898
Name:PEDIATRIC & ADOLESCENT CARE OF MN., P.A.
Entity type:Organization
Organization Name:PEDIATRIC & ADOLESCENT CARE OF MN., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DREELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-451-4700
Mailing Address - Street 1:1547 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3411
Mailing Address - Country:US
Mailing Address - Phone:651-451-8050
Mailing Address - Fax:
Practice Address - Street 1:1547 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3411
Practice Address - Country:US
Practice Address - Phone:651-451-8050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty