Provider Demographics
NPI:1568786150
Name:MINNESOTA COLON & RECTAL SURGICAL SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:MINNESOTA COLON & RECTAL SURGICAL SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-293-9977
Mailing Address - Street 1:2355 FAIRVIEW AVE N
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2724
Mailing Address - Country:US
Mailing Address - Phone:612-293-9977
Mailing Address - Fax:
Practice Address - Street 1:910 E 26TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4526
Practice Address - Country:US
Practice Address - Phone:612-293-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40267174400000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty