Basic Information
| Provider Information | |||||||||
| NPI: | 1407051154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGEVIEW CLINICS | ||||||||
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| OtherOrganizationName: | WESTERN ORTHOPAEDICS & SPORTS MEDICINE CONSULTANTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1007 | ||||||||
| Address2: | |||||||||
| City: | HOWARD LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553491007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205432591 | ||||||||
| FaxNumber: | 3205432693 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 6TH ST | ||||||||
| Address2: | |||||||||
| City: | HOWARD LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553495647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524423190 | ||||||||
| FaxNumber: | 9524423185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | BESSE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS & BUSINESS OFFICE MANAGE | ||||||||
| AuthorizedOfficialTelephone: | 9524427895 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9792 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207X00000X | 19168 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 673283600 | 05 | MN | MEDICAID |