Basic Information
| Provider Information | |||||||||
| NPI: | 1740332253 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGEVIEW CLINICS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIDGEVIEW WESTONKA CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427890 | ||||||||
| FaxNumber: | 9524427892 | ||||||||
| Practice Location | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427890 | ||||||||
| FaxNumber: | 9524427892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | BESSE | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9524427890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25217 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 672605400 | 05 | MN | MEDICAID |