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
State | License ID | Taxonomies |
---|---|---|
MN | 147 | 207K00000X, 207N00000X, 207Q00000X, 207R00000X, 207RE0101X, 207RI0200X, 207V00000X, 207W00000X, 207X00000X, 207Y00000X, 208000000X, 2083X0100X, 208600000X, 208800000X, 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 147 | Other | STATE PROF. REGISTRATION |
MN | 1014268 | Other | PREF ONE URGENT CARE # |
MN | AQ9091045486 | Other | PREFERRED ONE |
MN | 02071BR | Other | BCBS OF MN |
MN | 147 | Other | STATE PROF. REGISTRATION |
MN | CT1003 | Medicare ID - Type Unspecified | MEDICARE RAILROAD |