Provider Demographics
NPI:1710078738
Name:EDINA EYE PHYSICIANS AND SURGEONS PA
Entity Type:Organization
Organization Name:EDINA EYE PHYSICIANS AND SURGEONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-832-8143
Mailing Address - Street 1:7450 FRANCE AVE S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4787
Mailing Address - Country:US
Mailing Address - Phone:952-832-8100
Mailing Address - Fax:952-832-8148
Practice Address - Street 1:209 CHALUPSKY AVE SE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-2448
Practice Address - Country:US
Practice Address - Phone:952-758-7892
Practice Address - Fax:952-758-7894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7314104152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty