Provider Demographics
NPI:1427352087
Name:DOCTORS BY YOUR SIDE
Entity type:Organization
Organization Name:DOCTORS BY YOUR SIDE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-200-8028
Mailing Address - Street 1:6600 LYNDALE AV S
Mailing Address - Street 2:#120
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3398
Mailing Address - Country:US
Mailing Address - Phone:612-798-7688
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:6600 LYNDALE AV S
Practice Address - Street 2:#120
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-3398
Practice Address - Country:US
Practice Address - Phone:612-798-7688
Practice Address - Fax:612-869-3473
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOCTORS BY YOUR SIDE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-22
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39791207R00000X
MN631213E00000X
MN303213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO5835Medicare PIN
MN6576480001Medicare NSC