Organization
INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. STACY KOWALKOWSKI R.N. (ADMINISTRATOR)
(320) 229-1500
Entity
Organization
Contact information
Practice address
2301 CONNECTICUT AVENUE SOUTH, SARTELL, MN 56377-2474
(320) 229-1500
(320) 229-1505
Mailing address
2301 CONNECTICUT AVENUE SOUTH, SARTELL, MN 56377-2474
(320) 229-1500
(320) 229-1505
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
41961
MN
208VP0014X
Interventional Pain Medicine Physician
41961
MN
261QP2000X
Physical Therapy Clinic/Center
41961
MN
261QP3300X
Pain Clinic/Center
Primary
41961
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
410645800
—
MN
01
—
C03449
MEDICARE PTAN
MN
Enumeration date
02/06/2007
Last updated
07/14/2015
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