Provider Demographics
NPI:1043556517
Name:NOBLE PARKWAY MEDICAL CLINIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:NOBLE PARKWAY MEDICAL CLINIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAJUDEEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:FAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-496-1562
Mailing Address - Street 1:4808 85TH AVE NORTH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443
Mailing Address - Country:US
Mailing Address - Phone:763-496-1562
Mailing Address - Fax:763-657-0581
Practice Address - Street 1:4808 85TH AVE NORTH
Practice Address - Street 2:SUITE 300
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443
Practice Address - Country:US
Practice Address - Phone:763-496-1562
Practice Address - Fax:763-657-0581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care