MEDICARE: TUBMAN

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	8004872MHC	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

General Provider Information

NPI Number	:	1376655159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TUBMAN

Provider Business Mailing Address
First Line	:	4432 CHICAGO AVENUE SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407
Country	:	US
Telephone Number	:	612-870-2444
Fax Number	:	612-870-2428

Provider Business Practice Location Address
First Line	:	4432 CHICAGO AVENUE SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407
Country	:	US
Telephone Number	:	612-870-2444
Fax Number	:	612-870-2428

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BEVERLY DUSSO
Credential	:
Telephone Number	:	612-767-6690

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	11/04/2008

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Directions to “TUBMAN ” Practice Location

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