Basic Information
| Provider Information | |||||||||
| NPI: | 1528364429 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGEVIEW MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | RIDGEVIEW MEDICAL CENTER CRNAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 28TH AVE N | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554474835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635593779 | ||||||||
| FaxNumber: | 7634503986 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
| FaxNumber: | 9524428029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESDIENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9524422191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIDGEVIEW MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.