Provider Demographics
NPI:1376594507
Name:FACCO, RAYMOND J (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:FACCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN STE 500
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5349
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:11995 SINGLETREE LN STE 500
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5349
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00539892085R0202X
IN010423012085R0202X
AZ373862085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN163520DMedicare ID - Type Unspecified
IN000000092612OtherANTHEM
INFA4111631Medicare ID - Type Unspecified
INF82059Medicare UPIN
IN190320FMedicare ID - Type Unspecified
IN924750VMedicare ID - Type Unspecified
IN147380FMedicare ID - Type Unspecified
IN925240WMedicare ID - Type Unspecified
IN055740YMedicare ID - Type Unspecified
IN194930UMedicare ID - Type Unspecified
IN191150EMedicare ID - Type Unspecified