Provider Demographics
NPI:1952181935
Name:PALLIATIVE PROVIDERS, PA
Entity Type:Organization
Organization Name:PALLIATIVE PROVIDERS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:SOUKUP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:651-247-4727
Mailing Address - Street 1:4707 HIGHWAY 61 N STE 116
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3227
Mailing Address - Country:US
Mailing Address - Phone:651-247-4727
Mailing Address - Fax:
Practice Address - Street 1:4707 HIGHWAY 61 N STE 116
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3227
Practice Address - Country:US
Practice Address - Phone:651-247-4727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based