1932173374 NPI number — MINNESOTA EYE CONSULTANTS, PA

Table of content: (NPI 1932173374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932173374 NPI number — MINNESOTA EYE CONSULTANTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINNESOTA EYE CONSULTANTS, 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:
1932173374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9801 DUPONT AVE S
Provider Second Line Business Mailing Address:
SUITE 425
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-888-5800
Provider Business Mailing Address Fax Number:
952-567-6156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10709 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-5509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-888-5800
Provider Business Practice Location Address Fax Number:
763-553-1137
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILDE
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-567-6143

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 680090400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24D2023185 . This is a "CLIA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: CG8516 . This is a "RR MEDICARE GROUP NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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