Provider Demographics
NPI:1669496345
Name:MNGI ENDOSCOPY ASC INC
Entity Type:Organization
Organization Name:MNGI ENDOSCOPY ASC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KETOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-871-1145
Mailing Address - Street 1:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:3001 BROADWAY ST NE STE 500
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherLICENSE