Provider Demographics
NPI:1093778292
Name:PEDIATRIC SURGICAL ASSOCIATES LTD
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUISELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-813-8006
Mailing Address - Street 1:4530 W 77TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5006
Mailing Address - Country:US
Mailing Address - Phone:952-835-9442
Mailing Address - Fax:952-835-9443
Practice Address - Street 1:2530 CHICAGO AVE
Practice Address - Street 2:SUITE 550
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4289
Practice Address - Country:US
Practice Address - Phone:612-813-8000
Practice Address - Fax:612-813-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN360710100Medicaid
01176Medicare ID - Type Unspecified