Healthcare Provider Details

I. General information

NPI: 1932597002
Provider Name (Legal Business Name): MINNESOTA DOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 ENERGY PARK DR
SAINT PAUL MN
55108-5274
US

IV. Provider business mailing address

1450 ENERGY PARK DR
SAINT PAUL MN
55108-5274
US

V. Phone/Fax

Practice location:
  • Phone: 651-361-7200
  • Fax: 651-642-0223
Mailing address:
  • Phone: 651-361-7200
  • Fax: 651-642-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR172606-6
License Number StateMN

VIII. Authorized Official

Name: DR. DAVID A PAULSON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 612-390-4747