Provider Demographics
NPI:1336175744
Name:EAR NOSE & THROAT SPECIALTY CARE OF MINNESOTA PA
Entity Type:Organization
Organization Name:EAR NOSE & THROAT SPECIALTY CARE OF MINNESOTA PA
Other - Org Name:ENT SPECIALTY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:JABLONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-236-1692
Mailing Address - Street 1:6099 WAYZATA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5538
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:6099 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5538
Practice Address - Country:US
Practice Address - Phone:612-871-1144
Practice Address - Fax:612-871-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN234810100Medicaid