MEDICARE: MIDWEST GROUP HOME

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	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	395666	OTHER	MN	MINNESOTA DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1871193417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST GROUP HOME

Provider Business Mailing Address
First Line	:	4232 5TH ST NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2860
Country	:	US
Telephone Number	:	612-205-4918
Fax Number	:

Provider Business Practice Location Address
First Line	:	4232 5TH ST NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2860
Country	:	US
Telephone Number	:	612-205-4918
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ABDIKADIR M HASSAN
Credential	:
Telephone Number	:	612-205-4918

Provider Enumeration Date	:	10/30/2020
Last Update Date	:	11/01/2020

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Directions to “MIDWEST GROUP HOME ” Practice Location

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