Provider Demographics
NPI:1649370396
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:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-586-5877
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 1:10000 ZANE AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1400
Practice Address - Country:US
Practice Address - Phone:763-569-6281
Practice Address - Fax:763-569-6211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN262454-93336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10118513OtherIPC NUMBER
MN076751OtherANDA
MN831146OtherMCKESSON
MN2426220OtherNABP NUMBER
MN02071BROtherBCBS DME NUMBER
MN02071BROtherBCBS DME NUMBER