Basic Information
| Provider Information | |||||||||
| NPI: | 1275608457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGEVIEW MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
| FaxNumber: | 9524428052 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
| FaxNumber: | 9524428052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 9524422191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 0254 | MN | N | Transportation Services | Ambulance | 341600000X | 0046 | MN | N | Transportation Services | Ambulance | 341600000X | 0021 | MN | N | Transportation Services | Ambulance | 282N00000X | 331057 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 975245500 | 05 | MN | MEDICAID |