Healthcare Provider Details

I. General information

NPI: 1538559414
Provider Name (Legal Business Name): T. MCNIFF, M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5861 CEDAR LAKE RD S
MINNEAPOLIS MN
55416-1653
US

IV. Provider business mailing address

5861 CEDAR LAKE RD S
MINNEAPOLIS MN
55416-1653
US

V. Phone/Fax

Practice location:
  • Phone: 763-544-1000
  • Fax: 763-266-2382
Mailing address:
  • Phone: 763-544-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31205
License Number StateMN

VIII. Authorized Official

Name: DR. THOMAS R MCNIFF
Title or Position: OWNER
Credential: M.D.
Phone: 763-544-1000