Provider Demographics
NPI:1578670188
Name:INDIAN HEALTH BOARD OF MINNEAPOLIS
Entity type:Organization
Organization Name:INDIAN HEALTH BOARD OF MINNEAPOLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HIM/BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-721-9830
Mailing Address - Street 1:1315 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3975
Mailing Address - Country:US
Mailing Address - Phone:612-721-9881
Mailing Address - Fax:612-721-9870
Practice Address - Street 1:2020 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3104
Practice Address - Country:US
Practice Address - Phone:612-721-9800
Practice Address - Fax:612-721-9870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIAN HEALTH BOARD OF MINNEAPOLIS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-23
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6115875261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN360617100Medicaid