1558602607 NPI number — MINNESOTA MEDICAL IMAGING, LLC

Table of content: (NPI 1558602607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558602607 NPI number — MINNESOTA MEDICAL IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA MEDICAL IMAGING, LLC
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:
1558602607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/26/2014
NPI Reactivation Date:
10/08/2014

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 FLORIDA AVE S
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
GOLDEN VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426-1719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-354-7905
Provider Business Mailing Address Fax Number:
612-315-4165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 FLORIDA AVE S
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55426-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-354-7905
Provider Business Practice Location Address Fax Number:
612-315-4165
Provider Enumeration Date:
03/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
NEWMAN
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER - HSI
Authorized Official Telephone Number:
612-964-1810

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X , 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: 1801130158 . This is a "NPI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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