MEDICARE: NORTHERN CARDIOVASCULAR CLINIC, PA

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1639799323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN CARDIOVASCULAR CLINIC, PA

Provider Business Mailing Address
First Line	:	6565 FRANCE AVE S STE 101
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2154
Country	:	US
Telephone Number	:	952-500-0653
Fax Number	:	952-892-0254

Provider Business Practice Location Address
First Line	:	6565 FRANCE AVE S STE 101
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55435-2154
Country	:	US
Telephone Number	:	952-500-0653
Fax Number	:	952-892-0254

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DOMINIC A PLUCINSKI
Credential	:	MD
Telephone Number	:	763-229-4006

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	04/22/2020

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