Healthcare Provider Details

I. General information

NPI: 1063801116
Provider Name (Legal Business Name): ACACIA MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SUNRISE DR
SAINT PETER MN
56082-5376
US

IV. Provider business mailing address

PO BOX 1993
BURNSVILLE MN
55337-0995
US

V. Phone/Fax

Practice location:
  • Phone: 507-931-2200
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number50217
License Number StateMN

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS MANAGER
Credential:
Phone: 702-453-3799