Provider Demographics
NPI:1932389897
Name:DR. BOBBY K. YANG M.D. MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:DR. BOBBY K. YANG M.D. MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NOU
Authorized Official - Middle Name:
Authorized Official - Last Name:THOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-646-5452
Mailing Address - Street 1:1047 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4751
Mailing Address - Country:US
Mailing Address - Phone:651-646-5452
Mailing Address - Fax:651-646-5658
Practice Address - Street 1:1047 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4751
Practice Address - Country:US
Practice Address - Phone:651-646-5452
Practice Address - Fax:651-646-5658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43270261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03699OtherMEDICARE GROUP
MN604682700Medicaid