1144588773 NPI number — DIGESTIVE ENDOSCOPY, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144588773 NPI number — DIGESTIVE ENDOSCOPY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE ENDOSCOPY, PA
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:
1144588773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5970 ARBOUR AVE
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:
55436-2521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-920-6638
Provider Business Mailing Address Fax Number:
612-725-2248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17322 91ST AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55311-5403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-416-0399
Provider Business Practice Location Address Fax Number:
763-416-0399
Provider Enumeration Date:
05/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DUANE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-416-0399

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  19698 , 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: 255716900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1033127964 . This is a "NPI 1" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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