1629169644 NPI number — EDINA EYE PHYSICIANS AND SURGEONS PA

Table of content: (NPI 1629169644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629169644 NPI number — EDINA EYE PHYSICIANS AND SURGEONS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDINA EYE PHYSICIANS AND SURGEONS 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:
1629169644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7450 FRANCE AVE S
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
EDINA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55435-4787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-832-8100
Provider Business Mailing Address Fax Number:
952-832-8148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 HUNDERTMARK RD
Provider Second Line Business Practice Location Address:
SUITE 105N
Provider Business Practice Location Address City Name:
CHASKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55318-4551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-906-7826
Provider Business Practice Location Address Fax Number:
952-906-7827
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAYNE
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
952-832-8143

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7314104 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 7314104 , 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)





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