Healthcare Provider Details

I. General information

NPI: 1902836133
Provider Name (Legal Business Name): MIDWEST SPINE & BRAIN INSTITUTE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date: 09/12/2018
Reactivation Date: 10/17/2018

III. Provider practice location address

1950 NORTHWESTERN AVE S STE 102
STILLWATER MN
55082-7615
US

IV. Provider business mailing address

1950 NORTHWESTERN AVE S STE 102
STILLWATER MN
55082-7615
US

V. Phone/Fax

Practice location:
  • Phone: 651-430-3800
  • Fax: 651-430-3827
Mailing address:
  • Phone: 651-430-3800
  • Fax: 651-430-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARI OHLAND
Title or Position: ADMINISTRATOR
Credential: MHA, CMPE
Phone: 651-430-3800