Basic Information
| Provider Information | |||||||||
| NPI: | 1194751552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS AND ORTHOPAEDIC SPECIALISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
| FaxNumber: | 9529469888 | ||||||||
| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
| FaxNumber: | 9529469888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9529469777 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 59836 | 01 | MN | HEALTHPARTNERS | OTHER | 3420A | 01 | MN | SELECT CARE | OTHER | CI4045 | 01 | MN | RAILROAD MEDICARE | OTHER | 89704 | 01 | MN | PERFERRED ONE | OTHER | 60D44SH | 01 | MN | BLUE CROSS/SHIELD | OTHER |