=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295977395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC AND YOUNG ADULT MEDICINE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2009
-----------------------------------------------------
Last Update Date | 12/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1655 BEAM AVE SUITE 108
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-256-6706
-----------------------------------------------------
Fax | 651-256-6707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1804 7TH ST W SUITE 200
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-256-6706
-----------------------------------------------------
Fax | 651-256-6710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | MS. TERRI M JOSEPH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-256-6706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 154
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------