Provider Demographics
NPI:1184973356
Name:NORTHMARK MEDICAL LLC
Entity type:Organization
Organization Name:NORTHMARK MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:D
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGLIND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-888-2613
Mailing Address - Street 1:1260 YANKEE DOODLE RD
Mailing Address - Street 2:# 202
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2201
Mailing Address - Country:US
Mailing Address - Phone:651-888-2613
Mailing Address - Fax:651-846-6777
Practice Address - Street 1:1260 YANKEE DOODLE RD
Practice Address - Street 2:# 202
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2201
Practice Address - Country:US
Practice Address - Phone:651-888-2613
Practice Address - Fax:651-846-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000828233335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
000828233OtherPEDORTHIST