Provider Demographics
NPI:1043898778
Name:SOUTHDALE MEDICAL PARTNERS CORPORATION
Entity type:Organization
Organization Name:SOUTHDALE MEDICAL PARTNERS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-961-4322
Mailing Address - Street 1:902 INWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6625
Mailing Address - Country:US
Mailing Address - Phone:651-815-6880
Mailing Address - Fax:
Practice Address - Street 1:902 INWOOD AVE N STE 902
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6625
Practice Address - Country:US
Practice Address - Phone:952-999-4049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-01
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty