Basic Information
| Provider Information | |||||||||
| NPI: | 1669631073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIRVIEW HEALTH SERVICES | ||||||||
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| OtherOrganizationName: | FAIRVIEW HEALTH SERVICES 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: | 6401 FRANCE AVE S | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529245000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | LENARZ | ||||||||
| AuthorizedOfficialFirstName: | LOIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7635593779 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.