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General NPI Number Information
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NPI Number | 1043898778
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Entity Type | Organization
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Legal Business Name | SOUTHDALE MEDICAL PARTNERS CORPORATION
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Dates
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Enumeration Date | 04/01/2021
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Last Update Date | 05/03/2023
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Provider Practice Location Address
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Address Line | 902 INWOOD AVE N STE 902
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City | OAKDALE
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State | MN
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Zip | 55128-6625
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Country | US
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Telephone | 952-999-4049
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Fax |
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Provider Business Mailing Address
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Address Line | 902 INWOOD AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55128-6625
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Country | US
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Telephone | 651-815-6880
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MITCHELL PAUL BRANDT
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Credential |
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Telephone | 612-961-4322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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