Basic Information
| Provider Information | |||||||||
| NPI: | 1871594341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNEAPOLIS RADIOLOGY ASSOCIATES, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2955 XENIUM LN N | ||||||||
| Address2: | SUITE 40 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633982203 | ||||||||
| FaxNumber: | 7633986533 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7636949000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | NORBY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT/CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7633982203 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0204X | 173 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 173 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | 173 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 173 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 16-00010 | 01 | MEDICA | OTHER | 11634MI | 01 | BCBS | OTHER | 724510600 | 05 | MN | MEDICAID |