=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770250052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINNESOTA MEDICAL SPECIALISTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2021
-----------------------------------------------------
Last Update Date | 08/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2355 HWY 36 WEST SUITE 400
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-557-8950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 ROLLINS AVE STE 3
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | HIRENKUMAR ITALIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-557-8950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------