Healthcare Provider Details

I. General information

NPI: 1235529272
Provider Name (Legal Business Name): ILBNC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

15700 37TH AVENUE NORTH SUITE 210
PLYMOUTH MN
55446-3662
US

IV. Provider business mailing address

3001 METRO DRIVE SUITE 330
BLOOMINGTON MN
55425-4506
US

V. Phone/Fax

Practice location:
  • Phone: 952-814-6600
  • Fax: 952-814-6700
Mailing address:
  • Phone: 952-814-6600
  • Fax: 952-814-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number365578
License Number StateMN

VIII. Authorized Official

Name: PATRICK WILFRED JUSTIN
Title or Position: DIRECTOR OF SURGERY CENTER
Credential: R.N.
Phone: 952-814-6600