MEDICARE: PAUL MARSHALL LLC

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	103G00000X	Clinical Neuropsychologist	LP1606	MN

General Provider Information

NPI Number	:	1962750026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL MARSHALL LLC

Provider Business Mailing Address
First Line	:	1811 WEIR DR STE 190
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55125-2292
Country	:	US
Telephone Number	:	651-738-8561
Fax Number	:	651-730-6657

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL STE 1440
Second Line	:	MEDICAL ARTS BLDG
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2718
Country	:	US
Telephone Number	:	612-460-8502
Fax Number	:	651-730-6657

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	AIMEE PETRA
Credential	:
Telephone Number	:	651-738-8561

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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Directions to “PAUL MARSHALL LLC ” Practice Location

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