Healthcare Provider Details

I. General information

NPI: 1932150117
Provider Name (Legal Business Name): COLUMBIA PARK MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 UNIVERSITY AVE NE SUITE 200
FRIDLEY MN
55432-4341
US

IV. Provider business mailing address

6401 UNIVERSITY AVE NE SUITE 200
FRIDLEY MN
55432-4341
US

V. Phone/Fax

Practice location:
  • Phone: 763-572-5710
  • Fax: 763-571-3008
Mailing address:
  • Phone: 763-572-5710
  • Fax: 763-571-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number147
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number147
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number147
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number147
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number147
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number147
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number147
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number147
License Number StateMN
# 9
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number147
License Number StateMN
# 10
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number147
License Number StateMN
# 11
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number147
License Number StateMN
# 12
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number147
License Number StateMN
# 13
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number147
License Number StateMN
# 14
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number147
License Number StateMN
# 15
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number147
License Number StateMN

VIII. Authorized Official

Name: JOEN V CONDON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 763-586-5839