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4432 Chicago Avenue South Minneapolis MN 55407 | |
| (612) 870-2444 | |
| (612) 870-2428 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 4432 Chicago Avenue South, Minneapolis, Minnesota |
| Authorized Official Name and Position | Beverly Dusso (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 6127676690 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4432 Chicago Avenue South Minneapolis MN 55407 Ph: (612) 870-2444 | 4432 Chicago Avenue South Minneapolis MN 55407 Ph: (612) 870-2444 |
| NPI Number | 1376655159 |
|---|---|
| Provider Enumeration Date | 08/31/2006 |
| Last Update Date | 11/04/2008 |
| Medicare PECOS PAC ID | 5991793572 |
|---|---|
| Medicare Enrollment ID | O20040503001331 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1376655159 | NPI | - | NPPES |
| 257080700 | Medicaid | MN |
| Provider Name | Beverly J Caruso |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1336256916 PECOS PAC ID: 0749286425 Enrollment ID: I20061020000280 |
| Provider Name | Birgit O Kelly |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1346420643 PECOS PAC ID: 9335299502 Enrollment ID: I20091029000726 |
| Provider Name | April L Wolfson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1093862732 PECOS PAC ID: 4789788688 Enrollment ID: I20100701000742 |
| Provider Name | Susan R Roeller |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1801193123 PECOS PAC ID: 8022293133 Enrollment ID: I20110504000408 |
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