Provider Demographics
NPI:1871975607
Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Entity type:Organization
Organization Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHRO/CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:REICHERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-577-2484
Mailing Address - Street 1:3475 PLYMOUTH BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1499
Mailing Address - Country:US
Mailing Address - Phone:763-577-2484
Mailing Address - Fax:763-577-1375
Practice Address - Street 1:3475 PLYMOUTH BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-1499
Practice Address - Country:US
Practice Address - Phone:763-577-2484
Practice Address - Fax:763-577-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC00801Medicare UPIN
MN7438150002Medicare NSC