Provider Demographics
NPI:1912069519
Name:NORTHERN LIGHTS PEDIATRIC & ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:NORTHERN LIGHTS PEDIATRIC & ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:MARIAN NELMS
Authorized Official - Last Name:MCCABE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-251-5280
Mailing Address - Street 1:3555 WILLOW LAKE BLVD.
Mailing Address - Street 2:SUITE 140
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4462
Mailing Address - Country:US
Mailing Address - Phone:651-251-5280
Mailing Address - Fax:651-251-5282
Practice Address - Street 1:3555 WILLOW LAKE BLVD.
Practice Address - Street 2:SUITE 140
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-4462
Practice Address - Country:US
Practice Address - Phone:651-251-5280
Practice Address - Fax:651-251-5282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29960NOOtherBCBS MN
MN744432000Medicaid
MN165339OtherUCARE