Provider Demographics
NPI:1154696813
Name:HEALTHSOURCE OF ST. PAUL- GRAND
Entity type:Organization
Organization Name:HEALTHSOURCE OF ST. PAUL- GRAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DREWS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-292-9247
Mailing Address - Street 1:1053 GRAND AVE
Mailing Address - Street 2:SUITE #114
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3022
Mailing Address - Country:US
Mailing Address - Phone:651-292-9247
Mailing Address - Fax:651-292-9257
Practice Address - Street 1:1053 GRAND AVE
Practice Address - Street 2:SUITE #114
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3022
Practice Address - Country:US
Practice Address - Phone:651-292-9247
Practice Address - Fax:651-292-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-14
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC4257261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center