=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033725197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED SURGICAL ASSOCIATES OF NORTHERN MINNESOTA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 07/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4325 9TH AVE W
-----------------------------------------------------
City | HIBBING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55746-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-461-2122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 15042
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55815-0042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DO/OWNER
-----------------------------------------------------
Name | DR. JOHN P BOLLINS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 218-461-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------