Basic Information
Provider Information | |||||||||
NPI: | 1518058536 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDINA EYE PHYSICIANS AND SURGEONS PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7450 FRANCE AVE S | ||||||||
Address2: | SUITE 100 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554354787 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528328100 | ||||||||
FaxNumber: | 9528328148 | ||||||||
Practice Location | |||||||||
Address1: | 290 MAIN ST NW | ||||||||
Address2: |   | ||||||||
City: | ELK RIVER | ||||||||
State: | MN | ||||||||
PostalCode: | 553301270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7632415878 | ||||||||
FaxNumber: | 7632415877 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2006 | ||||||||
LastUpdateDate: | 02/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYNE | ||||||||
AuthorizedOfficialFirstName: | CHERYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9528328143 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 7314104 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 207W00000X | 7314104 | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
No ID Information.