Healthcare Provider Details

I. General information

NPI: 1619157344
Provider Name (Legal Business Name): FAMILY HEALTHSERVICES MINNESOTA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HIGHWAY 96 W
SHOREVIEW MN
55126-1900
US

IV. Provider business mailing address

2025 SLOAN PL STE 35
SAINT PAUL MN
55117-2092
US

V. Phone/Fax

Practice location:
  • Phone: 651-788-4444
  • Fax: 651-483-8299
Mailing address:
  • Phone: 651-772-1572
  • Fax: 651-772-1889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1428
License Number StateMN

VIII. Authorized Official

Name: KEN PALATTAO
Title or Position: CAO
Credential:
Phone: 651-772-1572