Healthcare Provider Details

I. General information

NPI: 1225132566
Provider Name (Legal Business Name): CHILDRENS HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 NORTH SMITH AVENUE CHILDRENS SPECIALTY CLINICS STPL
ST PAUL MN
55102
US

IV. Provider business mailing address

5901 LINCOLN DRIVE, CBC-2-REV/PE
EDINA MN
55436-1611
US

V. Phone/Fax

Practice location:
  • Phone: 651-220-6000
  • Fax:
Mailing address:
  • Phone: 952-992-5398
  • Fax: 952-992-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number331019
License Number StateMN

VIII. Authorized Official

Name: MARC H GORELICK
Title or Position: PRESIDENT & CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 612-813-8031