MEDICARE: NEW HOPE CRYSTAL MEDICAL CLINIC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2092	OTHER	MN	HEALTHPARTNERS
2	97421NO	OTHER	MN	BLUES
3	93495050569001	OTHER	MN	PREFERRED ONE
4	30310462	OTHER	MN	METROPOLITAN HEALTH PLAN
5	0005733572	OTHER	MN	AETNA
6	P044	OTHER	MN	UCARE

General Provider Information

NPI Number	:	1841253366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW HOPE CRYSTAL MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	3501 DOUGLAS DR N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2415
Country	:	US
Telephone Number	:	763-535-9601
Fax Number	:	763-535-5601

Provider Business Practice Location Address
First Line	:	3501 DOUGLAS DR N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2415
Country	:	US
Telephone Number	:	763-535-9601
Fax Number	:	763-535-5601

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	ART FRETAG
Credential	:
Telephone Number	:	763-535-9601

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	08/22/2020

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Directions to “NEW HOPE CRYSTAL MEDICAL CLINIC ” Practice Location

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