Provider Demographics
NPI:1346468253
Name:FAIRVIEW MAPLE GROVE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:FAIRVIEW MAPLE GROVE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP RVENUE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-672-6594
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0147
Mailing Address - Country:US
Mailing Address - Phone:612-672-5390
Mailing Address - Fax:
Practice Address - Street 1:14500 99TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-898-1424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN490000069Medicare PIN