Provider Demographics
NPI:1063704807
Name:MIDWEST FOOT AND ANKLE SPECIALISTS, LLC
Entity type:Organization
Organization Name:MIDWEST FOOT AND ANKLE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-788-7274
Mailing Address - Street 1:11901 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3911
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:612-788-3408
Practice Address - Street 1:11901 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3911
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:612-788-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN631213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty