Basic Information
| Provider Information | |||||||||
| NPI: | 1679512172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CDI FAIRVIEW EDEN PRAIRIE LLC | ||||||||
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| OtherOrganizationName: | CENTER FOR DIAGNOSTIC IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | NW5765 | ||||||||
| Address2: | PO BOX 1450 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554855765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525428553 | ||||||||
| FaxNumber: | 9525136880 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 PRAIRIE CENTER DR | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523453805 | ||||||||
| FaxNumber: | 9522948217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSEN | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER ON THE BOARD SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9525436500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.