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General NPI Number Information
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NPI Number | 1417056698
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Entity Type | Organization
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Legal Business Name | COLUMBIA PARK MEDICAL GROUP, PA
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 13819 HANSON BLVD NW SUITE 100
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City | ANDOVER
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State | MN
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Zip | 55304-7608
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Country | US
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Telephone | 763-862-4445
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Fax | 763-862-4465
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Provider Business Mailing Address
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Address Line | 6401 UNIVERSITY AVE NE
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City | FRIDLEY
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State | MN
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Zip | 55432-4341
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Country | US
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Telephone | 763-572-5710
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Fax | 763-571-3008
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JOHN LOUIS WEIR
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Credential |
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Telephone | 763-586-5877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | 261566-8
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License Number State | MN
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