MEDICARE: MARACON HEALTH CARE SERVICES, INC

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	332B00000X	Durable Medical Equipment & Medical Supplies		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70G05MA	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1982679700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARACON HEALTH CARE SERVICES, INC

Provider Business Mailing Address
First Line	:	1595 SELBY AVENUE, SUITE 201
Second Line	:
City	:	ST PAUL
State	:	MN
Zip	:	55104-6285
Country	:	US
Telephone Number	:	651-641-0895
Fax Number	:	651-641-0894

Provider Business Practice Location Address
First Line	:	1595 SELBY AVENUE
Second Line	:	SUITE 201
City	:	ST PAUL
State	:	MN
Zip	:	55104-6285
Country	:	US
Telephone Number	:	651-641-0895
Fax Number	:	651-641-0894

Authorized Official
Title or Position	:	CHIEF OF OPERATIONS
Name	:	MR. ONYEDIMMA NWACHUKU
Credential	:
Telephone Number	:	651-641-0895

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	12/05/2007

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