Provider Demographics
NPI:1306996335
Name:ST. PAUL INFECTIOUS DISEASE ASSOCIATES, LTD.
Entity type:Organization
Organization Name:ST. PAUL INFECTIOUS DISEASE ASSOCIATES, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HALLORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-772-6254
Mailing Address - Street 1:1959 SLOAN PL STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2073
Mailing Address - Country:US
Mailing Address - Phone:651-772-6235
Mailing Address - Fax:651-772-6261
Practice Address - Street 1:1959 SLOAN PL STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-2073
Practice Address - Country:US
Practice Address - Phone:651-772-6235
Practice Address - Fax:651-772-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN676363400Medicaid
MN676363400Medicaid