Provider Demographics
NPI:1003869140
Name:INTERVENTIONAL PROCEDURES GROUP LTD
Entity Type:Organization
Organization Name:INTERVENTIONAL PROCEDURES GROUP LTD
Other - Org Name:CENTER FOR DIAGNOSTIC IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER ON THE BOARD SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-543-6500
Mailing Address - Street 1:5775 WAYZATA BLVD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:952-513-6880
Practice Address - Street 1:2445 NORTH MAYFAIR ROAD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-774-7226
Practice Address - Fax:414-774-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI01439Medicare PIN
WI46048Medicare PIN