Provider Demographics
NPI:1356585442
Name:MINNESOTA ONCOLOGY HEMATOLOGY, PA
Entity type:Organization
Organization Name:MINNESOTA ONCOLOGY HEMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-863-8585
Mailing Address - Street 1:480 OSBORNE RD NE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:763-786-1620
Mailing Address - Fax:763-780-3099
Practice Address - Street 1:480 OSBORNE RD NE
Practice Address - Street 2:SUITE 220
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:763-786-1620
Practice Address - Fax:763-780-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1076207RX0202X, 207VX0201X, 363L00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01828OtherMEDICARE ID