Healthcare Provider Details

I. General information

NPI: 1013056969
Provider Name (Legal Business Name): INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 CONNECTICUT AVENUE SOUTH
SARTELL MN
56377-2474
US

IV. Provider business mailing address

2301 CONNECTICUT AVENUE SOUTH
SARTELL MN
56377-2474
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-1500
  • Fax: 320-229-1505
Mailing address:
  • Phone: 320-229-1500
  • Fax: 320-229-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number41961
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number41961
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number41961
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number41961
License Number StateMN

VIII. Authorized Official

Name: MRS. STACY KOWALKOWSKI
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 320-229-1500