MEDICARE: INDIAN HEALTH BOARD OF MINNEAPOLIS

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)	6115875	MN

General Provider Information

NPI Number	:	1578670188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIAN HEALTH BOARD OF MINNEAPOLIS

Provider Business Mailing Address
First Line	:	1315 E 24TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-3975
Country	:	US
Telephone Number	:	612-721-9881
Fax Number	:	612-721-9870

Provider Business Practice Location Address
First Line	:	2020 MINNEHAHA AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-3104
Country	:	US
Telephone Number	:	612-721-9800
Fax Number	:	612-721-9870

Authorized Official
Title or Position	:	HIM/BILLING MANAGER
Name	:	TIA SHAW
Credential	:
Telephone Number	:	612-721-9830

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	06/01/2021

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