Healthcare Provider Details

I. General information

NPI: 1063656593
Provider Name (Legal Business Name): NATHAN TSEBOH CHOMILO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 EARLE BROWN DR PEDIATRICS
BROOKLYN CENTER MN
55430-2506
US

IV. Provider business mailing address

6000 EARLE BROWN DR PEDIATRICS
BROOKLYN CENTER MN
55430-2506
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-4909
  • Fax:
Mailing address:
  • Phone: 952-993-4909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number53869
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number53689
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: