Provider Demographics
NPI:1710133566
Name:INDEPENDENT PROFESSIONALS PC
Entity Type:Organization
Organization Name:INDEPENDENT PROFESSIONALS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-401-6200
Mailing Address - Street 1:50 INTERLACHEN LN
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-9469
Mailing Address - Country:US
Mailing Address - Phone:952-401-6200
Mailing Address - Fax:
Practice Address - Street 1:319 BARRY AVE S
Practice Address - Street 2:SUITE 300
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1658
Practice Address - Country:US
Practice Address - Phone:952-473-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42949207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND26051Medicare UPIN