Basic Information
| Provider Information | |||||||||
| NPI: | 1013004175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PLASTIC SURGERY, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6545 FRANCE AVE S STE 350 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202600 | ||||||||
| FaxNumber: | 9529202668 | ||||||||
| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVE S STE 350 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529202600 | ||||||||
| FaxNumber: | 9529202668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUEBECK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9529202600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MEDICAL DOCTOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 1389 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 579013100 | 05 | MN | MEDICAID | 18029 | 05 | ND | MEDICAID | 25685 | 01 | MN | HEALTH PARTNERS | OTHER | 2M749AD | 01 | MN | BLUE CROSS/BLUE SHIELD | OTHER | 221070615 | 01 | MN | METROPOLITAN HEALTH PLAN | OTHER | C721 | 01 | MN | U-CARE | OTHER |