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General NPI Number Information
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NPI Number | 1487949897
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Entity Type | Organization
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Legal Business Name | ADVANCED INTEGRATIVE MEDICINE
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 10/04/2011
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Provider Practice Location Address
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Address Line | 5 W MAIN ST
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City | CROSBY
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State | MN
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Zip | 56441-1421
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Country | US
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Telephone | 218-546-7333
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Fax | 218-546-7334
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Provider Business Mailing Address
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Address Line | 5 W MAIN ST
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City | CROSBY
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State | MN
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Zip | 56441-1421
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Country | US
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Telephone | 218-546-7333
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Fax | 218-546-7334
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Authorized Official
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Title or Position | EXECUTIVE MEDICAL DIRECTOR
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Name | DR. MARK BOSTROM
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Credential | D.O.
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Telephone | 218-546-7333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 38115
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License Number State | MN
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