Provider Demographics
NPI:1093703316
Name:WESTERN OB/GYN LTD
Entity Type:Organization
Organization Name:WESTERN OB/GYN LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:952-442-2137
Mailing Address - Street 1:560 S MAPLE ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1733
Mailing Address - Country:US
Mailing Address - Phone:952-442-2137
Mailing Address - Fax:952-442-5960
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:SUITE 130
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-442-2137
Practice Address - Fax:952-442-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN526810900Medicaid
MNC07440Medicare ID - Type Unspecified