1295910412 NPI number — PLASTIC SURGERY SPECIALISTS, PA

Table of content: (NPI 1295910412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295910412 NPI number — PLASTIC SURGERY SPECIALISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGERY SPECIALISTS, 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:
6
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:
1295910412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7373 FRANCE AVE S
Provider Second Line Business Mailing Address:
SUITE 510
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-830-1028
Provider Business Mailing Address Fax Number:
952-830-0091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7373 FRANCE AVE S
Provider Second Line Business Practice Location Address:
SUITE 510
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-4534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-830-1028
Provider Business Practice Location Address Fax Number:
952-830-0091
Provider Enumeration Date:
01/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VAN BEEK
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
LESTER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-830-1028

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25914 , 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: 251502400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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