Provider Demographics
NPI:1205933611
Name:COLUMBIA PARK MEDICAL GROUP, PA
Entity type:Organization
Organization Name:COLUMBIA PARK MEDICAL GROUP, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-586-5839
Mailing Address - Street 1:6401 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4341
Mailing Address - Country:US
Mailing Address - Phone:763-572-5710
Mailing Address - Fax:763-571-3008
Practice Address - Street 1:6341 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4946
Practice Address - Country:US
Practice Address - Phone:763-572-5718
Practice Address - Fax:763-572-0318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA PARK MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C734COOtherBCBS EYEWARE
MN21140OtherMEDICA EYEWARE
MN21-00011OtherEYECRAFT LAB
MN126906OtherUCARE EYEWARE