Provider Demographics
NPI:1285671263
Name:ADVANCED ORTHOPAEDIC SURGERY, P.A.
Entity Type:Organization
Organization Name:ADVANCED ORTHOPAEDIC SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CONRAD
Authorized Official - Last Name:GREGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-470-2231
Mailing Address - Street 1:6633 BRENDEN CT
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-7560
Mailing Address - Country:US
Mailing Address - Phone:952-470-2231
Mailing Address - Fax:
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04306Medicare ID - Type Unspecified