MEDICARE: UCFA PHYSICIANS NETWORK GROUP OF MINNESOTA

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1265185888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCFA PHYSICIANS NETWORK GROUP OF MINNESOTA

Provider Business Mailing Address
First Line	:	8930 CROSS PARK DR STE 3
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37923-4713
Country	:	US
Telephone Number	:	865-245-5265
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 S 7TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-1606
Country	:	US
Telephone Number	:	423-271-9911
Fax Number	:

Authorized Official
Title or Position	:	ACTING CHIEF OF PRMG
Name	:	THEO S STEPHENS
Credential	:
Telephone Number	:	423-271-9911

Provider Enumeration Date	:	02/02/2022
Last Update Date	:	02/02/2022

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