Provider Demographics
NPI:1508562240
Name:PAIN SPECIALIST OF MINNESOTA
Entity type:Organization
Organization Name:PAIN SPECIALIST OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-238-8580
Mailing Address - Street 1:5810 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2830
Mailing Address - Country:US
Mailing Address - Phone:612-235-6008
Mailing Address - Fax:612-235-6003
Practice Address - Street 1:5810 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2830
Practice Address - Country:US
Practice Address - Phone:612-235-6008
Practice Address - Fax:612-235-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty