Provider Demographics
NPI:1962409995
Name:NORTH STAR PODIATRIC LAB, INC.
Entity type:Organization
Organization Name:NORTH STAR PODIATRIC LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDORTHIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:651-426-9388
Mailing Address - Street 1:13419 FENWAY BLVD N
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7465
Mailing Address - Country:US
Mailing Address - Phone:651-426-9388
Mailing Address - Fax:651-426-7450
Practice Address - Street 1:13419 FENWAY BLVD N
Practice Address - Street 2:SUITE 101
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-7465
Practice Address - Country:US
Practice Address - Phone:651-426-9388
Practice Address - Fax:651-426-7450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM908817200Medicaid
MN26569NOOtherBLUE CROSS PROVIDER NUMBE
MN66OtherHEALTH PARTNERS PROVIDER
MN418173203OtherMETRO HEALTH PLAN PROV NU
FM8214553OtherMEDICA PROVIDER NUMBER
MN66OtherHEALTH PARTNERS PROVIDER