MEDICARE: CEDAR RIVERSIDE PEOPLE'S CENTER

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	207QA0000X	Adolescent Medicine (Family Medicine) Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)		MN

General Provider Information

NPI Number	:	1851695514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR RIVERSIDE PEOPLE'S CENTER

Provider Business Mailing Address
First Line	:	425 20TH AVENUE SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55454-4400
Country	:	US
Telephone Number	:	612-332-4973
Fax Number	:	612-238-3534

Provider Business Practice Location Address
First Line	:	2425 CHICAGO AVENUE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-3845
Country	:	US
Telephone Number	:	612-332-4973
Fax Number	:	612-238-3534

Authorized Official
Title or Position	:	CEO
Name	:	MRS. SAHRA NOOR
Credential	:
Telephone Number	:	612-332-4973

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	06/07/2016

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