Provider Demographics
NPI:1437459211
Name:EDEN PRAIRIE CLINIC, PA
Entity Type:Organization
Organization Name:EDEN PRAIRIE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNA KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-944-6989
Mailing Address - Street 1:9358 ENSIGN AVE S
Mailing Address - Street 2:SUITE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1472
Mailing Address - Country:US
Mailing Address - Phone:952-944-6989
Mailing Address - Fax:
Practice Address - Street 1:9358 ENSIGN AVE S
Practice Address - Street 2:SUITE C
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1472
Practice Address - Country:US
Practice Address - Phone:952-944-6989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty