Basic Information
| Provider Information | |||||||||
| NPI: | 1235539180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA ENDOSCOPY CENTER. LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14909 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554140909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Practice Location | |||||||||
| Address1: | 2635 UNIVERSITY AVE W | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | KETOVER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6128705408 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.