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General NPI Number Information
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NPI Number | 1932597002
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Entity Type | Organization
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Legal Business Name | MINNESOTA DOC
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Dates
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Enumeration Date | 12/24/2014
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 1450 ENERGY PARK DR
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City | SAINT PAUL
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State | MN
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Zip | 55108-5274
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Country | US
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Telephone | 651-361-7200
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Fax | 651-642-0223
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Provider Business Mailing Address
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Address Line | 1450 ENERGY PARK DR
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City | SAINT PAUL
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State | MN
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Zip | 55108-5274
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Country | US
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Telephone | 651-361-7200
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Fax | 651-642-0223
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. DAVID A PAULSON
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Credential | MD
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Telephone | 612-390-4747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | R172606-6
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License Number State | MN
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