Provider Demographics
NPI:1215010335
Name:EDINA SPORTS HEALTH & WELLNESS, PA
Entity Type:Organization
Organization Name:EDINA SPORTS HEALTH & WELLNESS, PA
Other - Org Name:EDINA SPORTS AND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAUBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-926-6489
Mailing Address - Street 1:7701 YORK AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5864
Mailing Address - Country:US
Mailing Address - Phone:952-926-6489
Mailing Address - Fax:952-926-6501
Practice Address - Street 1:7701 YORK AVE S STE 300
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5864
Practice Address - Country:US
Practice Address - Phone:952-926-6489
Practice Address - Fax:952-926-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550095800Medicaid
MN6013040001Medicare NSC
MNC03159Medicare UPIN