Provider Demographics
NPI:1932150117
Name:COLUMBIA PARK MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:COLUMBIA PARK MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-586-5839
Mailing Address - Street 1:6401 UNIVERSITY AVE NE
Mailing Address - Street 2:SUITE 200
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 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4341
Practice Address - Country:US
Practice Address - Phone:763-572-5710
Practice Address - Fax:763-571-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN147207K00000X, 207N00000X, 207Q00000X, 207R00000X, 207RE0101X, 207RI0200X, 207V00000X, 207W00000X, 207X00000X, 207Y00000X, 208000000X, 2083X0100X, 208600000X, 208800000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN147OtherSTATE PROF. REGISTRATION
MN1014268OtherPREF ONE URGENT CARE #
MNAQ9091045486OtherPREFERRED ONE
MN02071BROtherBCBS OF MN
MN147OtherSTATE PROF. REGISTRATION
MNCT1003Medicare ID - Type UnspecifiedMEDICARE RAILROAD