Basic Information
| Provider Information | |||||||||
| NPI: | 1740683515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAMBER HEALTH OF MINNESOTA, P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TAMBER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 178 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL BAY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553230178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554826237 | ||||||||
| FaxNumber: | 9524059163 | ||||||||
| Practice Location | |||||||||
| Address1: | 2657 WOODBRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | WAYZATA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553919406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554826237 | ||||||||
| FaxNumber: | 9524059163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUNDELL | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8554826237 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | 47562 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) |
No ID Information.