MEDICARE: SOUTHDALE ALLERGY AND ASTHMA CLINIC, LLC

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	207K00000X	Allergy & Immunology Physician	23905	MN

General Provider Information

NPI Number	:	1477680718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHDALE ALLERGY AND ASTHMA CLINIC, LLC

Provider Business Mailing Address
First Line	:	4010 W 65TH ST
Second Line	:	#221
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55435-1721
Country	:	US
Telephone Number	:	952-926-7630
Fax Number	:	952-926-2116

Provider Business Practice Location Address
First Line	:	4010 W 65TH ST
Second Line	:	#221
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55435-1721
Country	:	US
Telephone Number	:	952-926-7630
Fax Number	:	952-926-2116

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. PAULINE SCHINDELDECKER
Credential	:
Telephone Number	:	952-926-7630

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	08/22/2020

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