Provider Demographics
NPI:1205145273
Name:IHS OF WOODBURY, P.A.
Entity type:Organization
Organization Name:IHS OF WOODBURY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KARY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-731-1880
Mailing Address - Street 1:1815 SUBURBAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4302
Mailing Address - Country:US
Mailing Address - Phone:651-731-1880
Mailing Address - Fax:651-739-6029
Practice Address - Street 1:1815 SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4302
Practice Address - Country:US
Practice Address - Phone:651-731-1880
Practice Address - Fax:651-739-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4486111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN762240600Medicaid
MN556P8KAOtherBLUECROSS BLUESHIELD
MN762240600Medicaid