Provider Demographics
NPI:1518922160
Name:RIVERSIDE UROLOGY, LLC
Entity Type:Organization
Organization Name:RIVERSIDE UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:D
Authorized Official - Last Name:THORNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-672-2525
Mailing Address - Street 1:7801 E BUSH LAKE RD
Mailing Address - Street 2:#320
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3120
Mailing Address - Country:US
Mailing Address - Phone:952-831-5773
Mailing Address - Fax:952-831-7224
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-672-2525
Practice Address - Fax:612-672-2970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03223Medicare ID - Type Unspecified