MEDICARE: PELVIC FLOOR CENTER, LLC

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	208C00000X	Colon & Rectal Surgery Physician		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538107743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PELVIC FLOOR CENTER, LLC

Provider Business Mailing Address
First Line	:	3433 BROADWAY ST NE
Second Line	:	SUITE 115
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1740
Country	:	US
Telephone Number	:	651-312-1520
Fax Number	:	651-312-1593

Provider Business Practice Location Address
First Line	:	2800 CHICAGO AVE S
Second Line	:	SUITE 300
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1353
Country	:	US
Telephone Number	:	651-225-7800
Fax Number	:	651-312-1570

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	DR. MICHAEL PAUL SPENCER
Credential	:	MD
Telephone Number	:	651-225-7800

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	04/28/2017

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