Basic Information
| Provider Information | |||||||||
| NPI: | 1750544862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREEMAN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 CAMPUS DR STE 10 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2955 XENIUM LN N STE 40 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 09/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 52220 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P01215717 | 01 | MN | RAILROAD MEDICARE | OTHER | ENROLLED | 05 | MN | MEDICAID |