Basic Information
| Provider Information | |||||||||
| NPI: | 1558316620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDELMAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 39480 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1016758 | 01 | MN | PREFERRED ONE | OTHER | 10R69ED | 01 | MN | BLUE CROSS | OTHER | 122865 | 01 | MN | UCARE | OTHER | 029R6ED | 01 | MN | BLUE CROSS | OTHER | 3000088626 | 01 | MN | RAILROAD MEDICARE MN | OTHER | 0527200 | 05 | IA | MEDICAID | 32646700 | 05 | WI | MEDICAID | HP26146 | 01 | MN | HEALTHPARTNERS | OTHER | 051020300 | 05 | MN | MEDICAID | 300127014 | 01 | WI | RAILROAD MEDICARE WI | OTHER | 777973 | 01 | MN | AMERICA'S PPO | OTHER |