Basic Information
| Provider Information | |||||||||
| NPI: | 1538107743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PELVIC FLOOR CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513121520 | ||||||||
| FaxNumber: | 6513121593 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 CHICAGO AVE S | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512257800 | ||||||||
| FaxNumber: | 6513121570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | SPENCER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6512257800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 353617300 | 05 | MN | MEDICAID |