Healthcare Provider Details

I. General information

NPI: 1669556668
Provider Name (Legal Business Name): PEDIATRIC ENT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E 26TH ST SUITE 323
MINNEAPOLIS MN
55404-4526
US

IV. Provider business mailing address

910 E 26TH ST SUITE 323
MINNEAPOLIS MN
55404-4526
US

V. Phone/Fax

Practice location:
  • Phone: 612-874-1292
  • Fax:
Mailing address:
  • Phone: 612-874-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: BARBARA A HEIMERL
Title or Position: MANAGER
Credential:
Phone: 612-874-1292