Provider Demographics
NPI:1114962214
Name:BARIATRIC SPECIALISTS OF MINNESOTA
Entity Type:Organization
Organization Name:BARIATRIC SPECIALISTS OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:651-227-6351
Mailing Address - Street 1:310 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2383
Mailing Address - Country:US
Mailing Address - Phone:651-227-6351
Mailing Address - Fax:
Practice Address - Street 1:310 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2393
Practice Address - Country:US
Practice Address - Phone:651-227-6351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03933Medicare ID - Type Unspecified