MEDICARE: MCKINLEY HRUBY MEDHAUG

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1578225355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKINLEY HRUBY MEDHAUG

Provider Business Mailing Address
First Line	:	430 OAK GROVE ST APT 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3686
Country	:	US
Telephone Number	:	651-968-7294
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 OAK GROVE ST APT 205
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-3686
Country	:	US
Telephone Number	:	651-968-7294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2021
Last Update Date	:	10/09/2021

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Directions to “ MCKINLEY HRUBY MEDHAUG ” Practice Location

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