Healthcare Provider Details

I. General information

NPI: 1518187434
Provider Name (Legal Business Name): MAPLE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7261 OHMS LN
EDINA MN
55439-2148
US

IV. Provider business mailing address

9825 HOSPITAL DRIVE, #105
MAPLE GROVE MN
55369
US

V. Phone/Fax

Practice location:
  • Phone: 952-843-4333
  • Fax: 952-843-4301
Mailing address:
  • Phone: 763-420-0580
  • Fax: 763-420-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number43570
License Number StateMN

VIII. Authorized Official

Name: MANAN S SHUKLA
Title or Position: CEO
Credential: M.D.
Phone: 952-843-4333