Provider Demographics
NPI:1740403393
Name:ADULT MEDICINE PA
Entity type:Organization
Organization Name:ADULT MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON-UZPEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-644-7775
Mailing Address - Street 1:393 DUNLAP ST N STE 235
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4208
Mailing Address - Country:US
Mailing Address - Phone:651-644-7775
Mailing Address - Fax:651-644-8884
Practice Address - Street 1:393 DUNLAP ST N STE 235
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4208
Practice Address - Country:US
Practice Address - Phone:651-644-7775
Practice Address - Fax:651-644-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN153133V00000X
MN26646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45Q68ANOtherBCBS
MNCH5440OtherRR MEDICARE
MN64544OtherHEALTHPARTNERS
MNCH5440OtherRR MEDICARE