1679512172 NPI number — CDI FAIRVIEW EDEN PRAIRIE LLC

Table of content: (NPI 1679512172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679512172 NPI number — CDI FAIRVIEW EDEN PRAIRIE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CDI FAIRVIEW EDEN PRAIRIE 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:
CENTER FOR DIAGNOSTIC IMAGING
Provider Other Organization Name Type Code:
3
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:
1679512172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NW5765
Provider Second Line Business Mailing Address:
PO BOX 1450
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55485-5765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-542-8553
Provider Business Mailing Address Fax Number:
952-513-6880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
775 PRAIRIE CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-7314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-345-3805
Provider Business Practice Location Address Fax Number:
952-294-8217
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSEN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OFFICER ON THE BOARD SECRETARY
Authorized Official Telephone Number:
952-543-6500

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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