MEDICARE: CRYSTAL NEW HOPE MEDICAL CLINIC INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	0005733572	OTHER	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	085N8NE	OTHER	BLUES
4	P044	OTHER	UCARE

General Provider Information

NPI Number	:	1366628554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL NEW HOPE MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	3501 DOUGLAS DR N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2415
Country	:	US
Telephone Number	:	763-535-9601
Fax Number	:	763-535-5601

Provider Business Practice Location Address
First Line	:	3501 DOUGLAS DR N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2415
Country	:	US
Telephone Number	:	763-535-9601
Fax Number	:	763-535-5601

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ROXANNE M URBASHICH
Credential	:
Telephone Number	:	763-535-9601

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	01/08/2013

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