Healthcare Provider Details

I. General information

NPI: 1740222496
Provider Name (Legal Business Name): LIFE MEDICAL, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 EXCELSIOR BLVD
SAINT LOUIS PARK MN
55416-4728
US

IV. Provider business mailing address

4201 EXCELSIOR BLVD
SAINT LOUIS PARK MN
55416-4728
US

V. Phone/Fax

Practice location:
  • Phone: 952-933-1121
  • Fax: 952-945-9536
Mailing address:
  • Phone: 952-933-8900
  • Fax: 952-945-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: JACOB I MIRMAN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 952-933-8900