MEDICARE: ST CATHERINE UNIVERSITY

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	2080A0000X	Pediatric Adolescent Medicine Physician	40727	MN

General Provider Information

NPI Number	:	1891016481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CATHERINE UNIVERSITY

Provider Business Mailing Address
First Line	:	2004 RANDOLPH AVE
Second Line	:	MAIL #4112
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1750
Country	:	US
Telephone Number	:	651-690-6714
Fax Number	:	651-690-6188

Provider Business Practice Location Address
First Line	:	2004 RANDOLPH AVE
Second Line	:	MAIL #4112
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1750
Country	:	US
Telephone Number	:	651-690-6714
Fax Number	:	651-690-6188

Authorized Official
Title or Position	:	MD
Name	:	AMY M KELLY
Credential	:	MD
Telephone Number	:	651-690-6714

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	06/17/2010

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Directions to “ST CATHERINE UNIVERSITY ” Practice Location

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