Provider Demographics
NPI:1134122054
Name:LIFESCAN MINNESOTA STAND UP MRI LLC
Entity Type:Organization
Organization Name:LIFESCAN MINNESOTA STAND UP MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-403-1401
Mailing Address - Street 1:5023 EXCELSIOR BLVD
Mailing Address - Street 2:STE 9B
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3013
Mailing Address - Country:US
Mailing Address - Phone:952-920-8860
Mailing Address - Fax:952-920-8869
Practice Address - Street 1:5023 EXCELSIOR BLVD
Practice Address - Street 2:STE 9B
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3013
Practice Address - Country:US
Practice Address - Phone:952-920-8860
Practice Address - Fax:952-920-8869
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESCAN MINNESOTA STAND UP MRI LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN377120200Medicaid
MN470000067Medicare PIN
MN470000036Medicare PIN