Provider Demographics
NPI:1346326196
Name:NORTHWEST EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:NORTHWEST EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-383-4140
Mailing Address - Street 1:8401 GOLDEN VALLEY RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4486
Mailing Address - Country:US
Mailing Address - Phone:763-383-4130
Mailing Address - Fax:763-383-4147
Practice Address - Street 1:5657 DULUTH ST
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4054
Practice Address - Country:US
Practice Address - Phone:763-416-7600
Practice Address - Fax:763-542-9708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN360207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN290445400Medicaid
MNCP2452Medicare PIN
MNC00447Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MN0353640006Medicare NSC