Provider Demographics
NPI:1407903248
Name:EDINA EYE PHYSICIANS AND SURGEONS PA
Entity Type:Organization
Organization Name:EDINA EYE PHYSICIANS AND SURGEONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DELTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-592-8413
Mailing Address - Street 1:3777 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-421-7420
Mailing Address - Fax:763-421-0730
Practice Address - Street 1:3777 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-421-7420
Practice Address - Fax:763-421-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA94112Medicare UPIN
MNH61350Medicare UPIN
MNA94926Medicare UPIN
MNA93782Medicare UPIN
MNU39362Medicare UPIN
MN1157570001Medicare NSC