Healthcare Provider Details

I. General information

NPI: 1891031209
Provider Name (Legal Business Name): MEDICAL ADDICTION TREATMENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 WASHINGTON AVE N
MINNEAPOLIS MN
55412-2141
US

IV. Provider business mailing address

3805 WASHINGTON AVE N
MINNEAPOLIS MN
55412-2141
US

V. Phone/Fax

Practice location:
  • Phone: 612-887-6282
  • Fax: 612-437-4992
Mailing address:
  • Phone: 612-887-6282
  • Fax: 612-437-4992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12684
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number52519
License Number StateMN

VIII. Authorized Official

Name: DR. ANNE M PYLKAS
Title or Position: CEO
Credential: MD
Phone: 612-435-7380