Healthcare Provider Details

I. General information

NPI: 1871926691
Provider Name (Legal Business Name): ANDREW MICHAEL MCCANN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 GOLF COURSE RD SUITE 104
GRAND RAPIDS MN
55744-3555
US

IV. Provider business mailing address

1542 GOLF COURSE RD SUITE 104
GRAND RAPIDS MN
55744-3555
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3300
  • Fax: 218-326-3400
Mailing address:
  • Phone: 218-326-3300
  • Fax: 218-326-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9386
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: