Provider Demographics
NPI:1174617146
Name:ST PAUL INTERNAL MEDICINE
Entity type:Organization
Organization Name:ST PAUL INTERNAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-645-9600
Mailing Address - Street 1:6200 SHINGLE CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2128
Mailing Address - Country:US
Mailing Address - Phone:763-561-5986
Mailing Address - Fax:763-561-6280
Practice Address - Street 1:514 ST PETER STREET
Practice Address - Street 2:SUITE 250
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-645-9600
Practice Address - Fax:651-645-9605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
MN31392207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10N38STOtherBCBS
MN0409583OtherMEDICA
MNDF1694OtherRAILROAD MEDICARE
MN938088400Medicaid
MN948448000Medicaid
MN0409583OtherMEDICA
MN938088400Medicaid