Provider Demographics
NPI:1396152211
Name:ST. PETER STREET CLINIC
Entity type:Organization
Organization Name:ST. PETER STREET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-645-9600
Mailing Address - Street 1:514 SAINT PETER ST
Mailing Address - Street 2:250
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1001
Mailing Address - Country:US
Mailing Address - Phone:651-645-9600
Mailing Address - Fax:651-888-2944
Practice Address - Street 1:514 SAINT PETER ST
Practice Address - Street 2:250
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1001
Practice Address - Country:US
Practice Address - Phone:651-645-9600
Practice Address - Fax:651-888-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B58414Medicare UPIN