Provider Demographics
NPI:1811999162
Name:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Entity type:Organization
Organization Name:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-721-9881
Mailing Address - Street 1:1315 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3975
Mailing Address - Country:US
Mailing Address - Phone:612-721-9800
Mailing Address - Fax:612-721-7870
Practice Address - Street 1:1315 E 24TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3975
Practice Address - Country:US
Practice Address - Phone:612-721-9800
Practice Address - Fax:612-721-7870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6115875261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN844522200Medicaid
MN916817600Medicaid
MN946883800Medicaid
MN634930700Medicaid
MN730320300Medicaid
MN781137300Medicaid
MN138488100Medicaid
MN934633300Medicaid
MN125028100Medicaid
MN206817600Medicaid
MN996488600Medicaid
MN942317600Medicaid
MNH02937Medicare UPIN
MN946883800Medicaid
MN781137300Medicaid
MN125028100Medicaid
MNF49177Medicare UPIN
MN844522200Medicaid
MN730320300Medicaid
MN634930700Medicaid