Provider Demographics
NPI:1053344788
Name:ST PAUL RHEUMATOLOGY P A
Entity type:Organization
Organization Name:ST PAUL RHEUMATOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-644-4277
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 190
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2156
Mailing Address - Country:US
Mailing Address - Phone:651-644-4277
Mailing Address - Fax:
Practice Address - Street 1:2854 HIGHWAY 55
Practice Address - Street 2:SUITE 190
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2156
Practice Address - Country:US
Practice Address - Phone:651-644-4277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN569199100Medicaid