MEDICARE: EBENEZER SOCIETY

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	314000000X	Skilled Nursing Facility	245587	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NA0018	OTHER	MN	UCARE
3	7100344	OTHER	MN	MEDICA DUAL

General Provider Information

NPI Number	:	1184622870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBENEZER SOCIETY

Provider Business Mailing Address
First Line	:	2545 PORTLAND AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4406
Country	:	US
Telephone Number	:	612-879-2262
Fax Number	:	612-879-2316

Provider Business Practice Location Address
First Line	:	2545 PORTLAND AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4406
Country	:	US
Telephone Number	:	612-879-2262
Fax Number	:	612-879-2316

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. MARK THOMAS
Credential	:
Telephone Number	:	612-874-3460

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/13/2011

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Directions to “EBENEZER SOCIETY ” Practice Location

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