Provider Demographics
NPI:1285930313
Name:AFFINITY MEDICAL GROUP PA
Entity type:Organization
Organization Name:AFFINITY MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-551-1344
Mailing Address - Street 1:9446 36TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1718
Mailing Address - Country:US
Mailing Address - Phone:763-551-1344
Mailing Address - Fax:763-551-1544
Practice Address - Street 1:9446 36TH AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1718
Practice Address - Country:US
Practice Address - Phone:763-551-1344
Practice Address - Fax:763-551-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4547111N00000X
MN4505111N00000X
MN8833208100000X
MN447602081P2900X
MN9656363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6621420001Medicare NSC