Basic Information
| Provider Information | |||||||||
| NPI: | 1225249881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGEVIEW CLINICS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIDGEVIEW SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427895 | ||||||||
| FaxNumber: | 9524427894 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 S MAPLE ST | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
| FaxNumber: | 9524428019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | BESSE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9524427890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 22924 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RS0012X | 49463 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 49463 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 49463 | 01 | MN | RAVI LICENSE NO. | OTHER |