Provider Demographics
NPI:1770547317
Name:PAUL LARSON OB GYN CLINIC PA
Entity type:Organization
Organization Name:PAUL LARSON OB GYN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:IMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-927-4021
Mailing Address - Street 1:6525 FRANCE AVE S
Mailing Address - Street 2:STE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2158
Mailing Address - Country:US
Mailing Address - Phone:952-927-4021
Mailing Address - Fax:952-285-6183
Practice Address - Street 1:6525 FRANCE AVE S
Practice Address - Street 2:STE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-3624
Practice Address - Country:US
Practice Address - Phone:952-927-4021
Practice Address - Fax:952-285-6183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VC0200XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyCritical Care MedicineGroup - Multi-Specialty