Provider Demographics
NPI:1588600043
Name:IHS MIDWEST PC
Entity type:Organization
Organization Name:IHS MIDWEST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MASSOGLIA
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:651-334-1290
Mailing Address - Street 1:450 FORD RD
Mailing Address - Street 2:UNIT 101
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1058
Mailing Address - Country:US
Mailing Address - Phone:651-334-1290
Mailing Address - Fax:
Practice Address - Street 1:211 HIGHWAY 25 S
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-9306
Practice Address - Country:US
Practice Address - Phone:651-334-1290
Practice Address - Fax:763-295-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X, 261QP3300X
MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04047Medicare ID - Type UnspecifiedGROUP NUMBER