Provider Demographics
NPI:1114921996
Name:OPHTHALMOLOGY PA
Entity Type:Organization
Organization Name:OPHTHALMOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-848-8312
Mailing Address - Street 1:3100 W 70TH ST
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4227
Mailing Address - Country:US
Mailing Address - Phone:952-848-8300
Mailing Address - Fax:952-848-8313
Practice Address - Street 1:3100 W 70TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4227
Practice Address - Country:US
Practice Address - Phone:952-848-8300
Practice Address - Fax:952-848-8312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0026007207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN585010000Medicaid
MNCP4332OtherRAILROAD MEDICARE
MND044OtherUCARE MINNESOTA
MN130790POtherBLUE SHIELD OF MINNESOTA
MN156OtherHEALTH PARTNERS
MN585010000Medicaid
MNC00827Medicare PIN