Provider Demographics
NPI:1639354541
Name:MARK C. ENGASSER, M.D.P.A.
Entity Type:Organization
Organization Name:MARK C. ENGASSER, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SYKORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-915-8327
Mailing Address - Street 1:6600 FRANCE AVE S
Mailing Address - Street 2:SUITE 605
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1805
Mailing Address - Country:US
Mailing Address - Phone:952-920-4333
Mailing Address - Fax:952-920-2561
Practice Address - Street 1:2000 PLYMOUTH RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2366
Practice Address - Country:US
Practice Address - Phone:952-920-4333
Practice Address - Fax:952-920-2561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22841332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2792972Medicaid
MN0549990002Medicare NSC
MNA95614Medicare UPIN