Healthcare Provider Details

I. General information

NPI: 1962769687
Provider Name (Legal Business Name): BW MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 STINSON BLVD NE STE 404
MINNEAPOLIS MN
55421-3424
US

IV. Provider business mailing address

17620 DURANT ST NE
HAM LAKE MN
55304-4602
US

V. Phone/Fax

Practice location:
  • Phone: 612-706-9630
  • Fax: 612-706-9617
Mailing address:
  • Phone: 763-413-9462
  • Fax: 612-706-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39788
License Number StateMN

VIII. Authorized Official

Name: KIMBERLY J. HAYCRAFT-WILLIAMS
Title or Position: OWNER
Credential: MD
Phone: 612-706-9630