Provider Demographics
NPI:1154416402
Name:MID-MINNESOTA NEUROLOGY CLINIC, P.A.
Entity type:Organization
Organization Name:MID-MINNESOTA NEUROLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THANH
Authorized Official - Middle Name:K
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-497-9906
Mailing Address - Street 1:13985 OAKWOOD CT NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4514
Mailing Address - Country:US
Mailing Address - Phone:763-497-9906
Mailing Address - Fax:763-497-9906
Practice Address - Street 1:206 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8665
Practice Address - Country:US
Practice Address - Phone:763-295-3844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37961261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2065185Medicaid
785177OtherAMERICA'S PPO
0500702OtherMEDICA
362G7MIOtherBCBS
J254OtherUCARE
J254OtherUCARE
785177OtherAMERICA'S PPO