MEDICARE: BW MEDICAL 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	207Q00000X	Family Medicine Physician	39788	MN

General Provider Information

NPI Number	:	1962769687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BW MEDICAL PA

Provider Business Mailing Address
First Line	:	17620 DURANT ST NE
Second Line	:
City	:	HAM LAKE
State	:	MN
Zip	:	55304-4602
Country	:	US
Telephone Number	:	763-413-9462
Fax Number	:	612-706-9617

Provider Business Practice Location Address
First Line	:	4001 STINSON BLVD NE
Second Line	:	STE 404
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55421-3424
Country	:	US
Telephone Number	:	612-706-9630
Fax Number	:	612-706-9617

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY J. HAYCRAFT-WILLIAMS
Credential	:	MD
Telephone Number	:	612-706-9630

Provider Enumeration Date	:	04/19/2012
Last Update Date	:	04/19/2012

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