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General NPI Number Information
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NPI Number | 1063704807
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Entity Type | Organization
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Legal Business Name | MIDWEST FOOT AND ANKLE SPECIALISTS, LLC
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Dates
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Enumeration Date | 05/12/2011
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Last Update Date | 05/12/2011
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Provider Practice Location Address
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Address Line | 11901 CENTRAL AVE NE
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City | BLAINE
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State | MN
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Zip | 55434-3911
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Country | US
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Telephone | 612-788-8778
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Fax | 612-788-3408
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Provider Business Mailing Address
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Address Line | 11901 CENTRAL AVE NE
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City | BLAINE
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State | MN
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Zip | 55434-3911
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Country | US
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Telephone | 612-788-8778
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Fax | 612-788-3408
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Authorized Official
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Title or Position | OWNER
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Name | BRYAN L MOHR
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Credential | DPM
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Telephone | 612-788-7274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 631
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License Number State | MN
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