Provider Demographics
NPI:1326019829
Name:MINNESOTA EYE CONSULTANTS, PA
Entity Type:Organization
Organization Name:MINNESOTA EYE CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-567-6043
Mailing Address - Street 1:9801 DUPONT AVE SOUTH
Mailing Address - Street 2:SUITE 425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3873
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:952-567-6156
Practice Address - Street 1:9801 DUPONT AVE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3180
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:952-567-6156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1751332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN334216601Medicaid
MN59Q32MIOtherBCBS GROUP OPTICAL
MN334216601Medicaid
MN1250440009Medicare NSC
MN1250440019Medicare NSC
MN1250440010Medicare NSC
MN1250440017Medicare NSC
MN1250440005Medicare NSC
MN1250440013Medicare NSC
MN1250440014Medicare NSC
MN1250440001Medicare NSC
MN1250440012Medicare NSC
MN1250440007Medicare NSC
MN59Q32MIOtherBCBS GROUP OPTICAL
MN1250440011Medicare NSC