MEDICARE: ACTIVE FEET, FOOT & ANKLE HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist

General Provider Information

NPI Number	:	1164716387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE FEET, FOOT & ANKLE HEALTH CENTER

Provider Business Mailing Address
First Line	:	6625 LYNDALE AVE S STE 300
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55423-2491
Country	:	US
Telephone Number	:	612-788-8778
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 STINSON BLVD STE 120
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55421-3424
Country	:	US
Telephone Number	:	612-788-8778
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN MOHR
Credential	:	DPM
Telephone Number	:	612-788-8778

Provider Enumeration Date	:	06/06/2011
Last Update Date	:	11/01/2018

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