Provider Demographics
NPI:1326357500
Name:AVANTI MEDICAL GROUP OF MINNESOTA LLC
Entity Type:Organization
Organization Name:AVANTI MEDICAL GROUP OF MINNESOTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF MEDICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:318-465-5874
Mailing Address - Street 1:1755 S NAPERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-5844
Mailing Address - Country:US
Mailing Address - Phone:318-465-5874
Mailing Address - Fax:
Practice Address - Street 1:1755 S NAPERVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5844
Practice Address - Country:US
Practice Address - Phone:318-465-5874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVANTI MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center