Healthcare Provider Details

I. General information

NPI: 1770123697
Provider Name (Legal Business Name): MINNESOTA ONCOLOGY HEMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 BEAM AVE
SAINT PAUL MN
55109-1127
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W STE 110N
SAINT PAUL MN
55114-2001
US

V. Phone/Fax

Practice location:
  • Phone: 651-779-7978
  • Fax: 651-779-7656
Mailing address:
  • Phone: 651-602-5335
  • Fax: 651-665-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOAN LOUISE THEIS
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 651-602-5326