Provider Demographics
NPI:1952546061
Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Entity type:Organization
Organization Name:UNIVERSITY OF MINNESOTA PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:COO
Authorized Official - Phone:612-884-0802
Mailing Address - Street 1:606 24TH AVE S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1455
Mailing Address - Country:US
Mailing Address - Phone:612-659-8689
Mailing Address - Fax:612-659-8690
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:812-659-8689
Practice Address - Fax:612-659-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN701372800Medicaid
MNC02390Medicare PIN