Healthcare Provider Details

I. General information

NPI: 1881753564
Provider Name (Legal Business Name): MEDICINE LAKE CONSULTATION GROUP,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 FORD ROAD UNIT B
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

1155 FORD ROAD UNIT B
ST LOUIS PARK MN
55426
US

V. Phone/Fax

Practice location:
  • Phone: 952-378-1800
  • Fax: 952-378-1714
Mailing address:
  • Phone: 952-378-1800
  • Fax: 952-378-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number103TC0700X
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2084P0800X
License Number State

VIII. Authorized Official

Name: MRS. ANI C RAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 952-378-1800