Healthcare Provider Details

I. General information

NPI: 1851378343
Provider Name (Legal Business Name): JOSEPH M BEBCHUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 OSBORNE RD NE SUITE 260
FRIDLEY MN
55432-2773
US

IV. Provider business mailing address

2925 CHICAGO AVE CREDENTIALING
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-3800
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number42300
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: