MEDICARE: JOHN MICHAEL IMP PHD., L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP2523	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HP38677	OTHER	MN	HEALTHPARTNERS
2	921001033636	OTHER	MN	PREFERRED ONE
3	143305	OTHER	MN	UCARE
4	362J3IM	OTHER	MN	BCBS OF MN

General Provider Information

NPI Number	:	1164559241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MICHAEL IMP PHD., L.P.

Provider Business Mailing Address
First Line	:	1357 WINDBREAK CT NE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-8587
Country	:	US
Telephone Number	:	507-289-5409
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 3RD AVE SE
Second Line	:	SUITE 405
City	:	ROCHESTER
State	:	MN
Zip	:	55904-4619
Country	:	US
Telephone Number	:	507-288-8544
Fax Number	:	507-288-8545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/09/2007

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