Provider Demographics
NPI:1487949897
Name:ADVANCED INTEGRATIVE MEDICINE
Entity type:Organization
Organization Name:ADVANCED INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:218-546-7333
Mailing Address - Street 1:5 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1421
Mailing Address - Country:US
Mailing Address - Phone:218-546-7333
Mailing Address - Fax:218-546-7334
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1421
Practice Address - Country:US
Practice Address - Phone:218-546-7333
Practice Address - Fax:218-546-7334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38115208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85419100Medicaid
MN85419100Medicaid