Provider Demographics
NPI:1497837306
Name:NORTHWEST EYE CLINIC, LLC
Entity Type:Organization
Organization Name:NORTHWEST EYE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:BAZHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-270-6658
Mailing Address - Street 1:8401 GOLDEN VALLEY RD STE 330
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4488
Mailing Address - Country:US
Mailing Address - Phone:763-416-7629
Mailing Address - Fax:763-383-4147
Practice Address - Street 1:8501 GOLDEN VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4472
Practice Address - Country:US
Practice Address - Phone:763-416-7600
Practice Address - Fax:763-416-7634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN360207W00000X
207WX0009X, 207WX0107X, 207WX0109X, 207WX0110X, 207WX0120X, 207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmologyGroup - Single Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases SpecialistGroup - Single Specialty
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110184600Medicaid
MN969008500Medicaid
MN160710300Medicaid
MN298616700Medicaid
MN607693900Medicaid
MN467427800Medicaid
MN221967100Medicaid
MN290445400Medicaid
MN467427800Medicaid
MN290445400Medicaid
MNCP2452Medicare PIN
MNC00447Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MN298616700Medicaid
MN221967100Medicaid
MN0353640002Medicare NSC
MN0353640007Medicare NSC
MN0353640001Medicare NSC
MN0353640009Medicare NSC
MN0353640004Medicare NSC