Provider Demographics
NPI:1033188156
Name:SU, EDWARD T (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:SU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7135
Practice Address - Country:US
Practice Address - Phone:651-968-5770
Practice Address - Fax:651-968-5775
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN47790207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN926459100Medicaid
MNP00265354OtherRAILROAD MEDICARE
MN926459100Medicaid
MN400000033Medicare PIN