1013004175 NPI number — MIDWEST PLASTIC SURGERY, P.A.

Table of content: (NPI 1013004175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013004175 NPI number — MIDWEST PLASTIC SURGERY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST PLASTIC SURGERY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013004175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6545 FRANCE AVE S STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-920-2600
Provider Business Mailing Address Fax Number:
952-920-2668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6545 FRANCE AVE S STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-920-2600
Provider Business Practice Location Address Fax Number:
952-920-2668
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUEBECK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
952-920-2600

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  1389 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 579013100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18029 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25685 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2M749AD . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 221070615 . This is a "METROPOLITAN HEALTH PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C721 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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