Provider Demographics
NPI:1437123270
Name:EDINA MN OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:EDINA MN OPHTHALMOLOGY ASC LLC
Other - Org Name:MCCANNEL EYE SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:3124 W 70TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4227
Practice Address - Country:US
Practice Address - Phone:952-848-8338
Practice Address - Fax:952-848-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327395261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN567492100Medicaid
MN567492100Medicaid
MN=========OtherTRIWEST HEALTHCARE ALLIAN
MN567492100Medicaid