Healthcare Provider Details

I. General information

NPI: 1881819886
Provider Name (Legal Business Name): STUDENT HEALTH SERVICE UNIVERSITY OF ST. THOMAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 SUMMIT AVE MAILBOX #5056
SAINT PAUL MN
55105-1048
US

IV. Provider business mailing address

2115 SUMMIT AVE MAILBOX #5056
SAINT PAUL MN
55105-1048
US

V. Phone/Fax

Practice location:
  • Phone: 651-962-6750
  • Fax: 651-962-6751
Mailing address:
  • Phone: 651-962-6750
  • Fax: 651-962-6751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberMN32783
License Number StateMN

VIII. Authorized Official

Name: MS. MADONNA K MC DERMOTT
Title or Position: DIRECTOR STUDENT HEALTH SERVICE
Credential: MS, MPA
Phone: 651-962-6750