Healthcare Provider Details

I. General information

NPI: 1023070554
Provider Name (Legal Business Name): PHYSICAL AND OCCUPATIONAL MEDICINE ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 PARK CENTER BLVD SUITE 311
ST LOUIS PARK MN
55416-2531
US

IV. Provider business mailing address

3601 PARK CENTER BLVD SUITE 311
ST LOUIS PARK MN
55416-2531
US

V. Phone/Fax

Practice location:
  • Phone: 952-922-2012
  • Fax: 952-922-2013
Mailing address:
  • Phone: 952-922-2012
  • Fax: 952-922-2913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number28205
License Number StateMN

VIII. Authorized Official

Name: JOHN GALIN SANDNESS
Title or Position: PRESIDENT
Credential: MD
Phone: 952-922-2012