Provider Demographics
NPI:1316162308
Name:IVANHOE CLINIC
Entity type:Organization
Organization Name:IVANHOE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MULDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-694-1232
Mailing Address - Street 1:121 W SAXON ST
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:MN
Mailing Address - Zip Code:56142-9504
Mailing Address - Country:US
Mailing Address - Phone:507-694-1232
Mailing Address - Fax:507-694-1171
Practice Address - Street 1:121 W SAXON ST
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:MN
Practice Address - Zip Code:56142-9504
Practice Address - Country:US
Practice Address - Phone:507-694-1232
Practice Address - Fax:507-694-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18873261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN158210100Medicaid
MN46119IVOtherBLUE CROSS BLUE SHIELD
MND48832Medicare UPIN
MN158210100Medicaid