Basic Information
| Provider Information | |||||||||
| NPI: | 1023097078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOEDLER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2355 HIGHWAY 36 W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551133905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2355 HIGHWAY 36 W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551133905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24320 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 574063100 | 05 | MN | MEDICAID |