Provider Demographics
NPI:1689727042
Name:WOMEN AND ADOLESCENTS GYNECOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:WOMEN AND ADOLESCENTS GYNECOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUDORA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRAZETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-224-7072
Mailing Address - Street 1:7300 FRANCE AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4525
Mailing Address - Country:US
Mailing Address - Phone:952-224-7072
Mailing Address - Fax:952-224-7073
Practice Address - Street 1:7300 FRANCE AVE S
Practice Address - Street 2:SUITE 201
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4525
Practice Address - Country:US
Practice Address - Phone:952-224-7072
Practice Address - Fax:952-224-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32031207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA64262Medicare UPIN