Provider Demographics
NPI:1275859423
Name:MCCUE PLASTIC SURGERY, PA
Entity Type:Organization
Organization Name:MCCUE PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-670-9076
Mailing Address - Street 1:7373 FRANCE AVE S
Mailing Address - Street 2:SUITE 510
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4534
Mailing Address - Country:US
Mailing Address - Phone:612-670-9076
Mailing Address - Fax:
Practice Address - Street 1:7373 FRANCE AVE S
Practice Address - Street 2:SUITE 510
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4534
Practice Address - Country:US
Practice Address - Phone:612-670-9076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI26903Medicare UPIN