Provider Demographics
NPI:1770972382
Name:ST PAUL PRIMARY CARE
Entity type:Organization
Organization Name:ST PAUL PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-817-6690
Mailing Address - Street 1:2707 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1631
Mailing Address - Country:US
Mailing Address - Phone:612-874-8811
Mailing Address - Fax:612-874-0020
Practice Address - Street 1:1345 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1410
Practice Address - Country:US
Practice Address - Phone:651-451-2711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST PAUL PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43414261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN100025256Medicaid
MN080022382OtherMEDICARE 080022382