MEDICARE: WEST SIDE COMMUNITY HEALTH SERVICES, 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	261QF0400X	Federally Qualified Health Center (FQHC)		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103124	OTHER	MN	UCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407049653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST SIDE COMMUNITY HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	153 CESAR CHAVEZ ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55107-2226
Country	:	US
Telephone Number	:	651-602-7500
Fax Number	:	651-602-7513

Provider Business Practice Location Address
First Line	:	1015 SNELLING AVE S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55116-2447
Country	:	US
Telephone Number	:	651-690-7667
Fax Number	:	651-690-7670

Authorized Official
Title or Position	:	CEO
Name	:	REUBEN MOORE
Credential	:
Telephone Number	:	651-602-7500

Provider Enumeration Date	:	08/21/2007
Last Update Date	:	05/15/2024

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