Basic Information
| Provider Information | |||||||||
| NPI: | 1578850046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDMONSON | ||||||||
| FirstName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 AMERICAN BLVD W | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554314420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528318742 | ||||||||
| FaxNumber: | 9528311626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 AMERICAN BLVD W | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554314420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528318742 | ||||||||
| FaxNumber: | 9528311626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9381 | AZ | N | Other Service Providers | Specialist | 2251X0800X | 8711 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.