Basic Information
| Provider Information | |||||||||
| NPI: | 1306986518 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINNEAPOLIS VASCULAR PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 CAMPUS DRIVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633982203 | ||||||||
| FaxNumber: | 7633982233 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 CAMPUS DRIVE | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633982203 | ||||||||
| FaxNumber: | 7633982233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORBY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT/CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7633982203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 8587602 | 01 | MN | MINNESOTA TAX ID NUMBER | OTHER |