MEDICARE: INDEPENDENT MEDICAL CLINIC PA

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	207R00000X	Internal Medicine Physician	44276	MN

General Provider Information

NPI Number	:	1316454077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT MEDICAL CLINIC PA

Provider Business Mailing Address
First Line	:	2639 NICOLLET AVE STE 120
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-1629
Country	:	US
Telephone Number	:	612-315-5145
Fax Number	:	855-670-9121

Provider Business Practice Location Address
First Line	:	2639 NICOLLET AVE STE 120
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-1629
Country	:	US
Telephone Number	:	612-315-5145
Fax Number	:	855-670-9121

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PATRICK R TOWNLEY
Credential	:	MD
Telephone Number	:	612-281-1298

Provider Enumeration Date	:	01/03/2018
Last Update Date	:	06/20/2019

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