Basic Information
| Provider Information | |||||||||
| NPI: | 1912971912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINNESOTA UROLOGY, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METRO UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996830 | ||||||||
| Practice Location | |||||||||
| Address1: | 6025 LAKE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519996800 | ||||||||
| FaxNumber: | 6519996830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILBANK | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | UROLOGIST, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6519997037 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | CP2429 | 01 | MN | MEDICARE RAILROAD | OTHER | 919208500 | 05 | MN | MEDICAID |