Provider Demographics
NPI:1720574445
Name:ECHELON SURGICAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:ECHELON SURGICAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-383-3134
Mailing Address - Street 1:12300 168TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9224
Mailing Address - Country:US
Mailing Address - Phone:507-383-3134
Mailing Address - Fax:
Practice Address - Street 1:15450 HIGHWAY 7 STE 225
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-3522
Practice Address - Country:US
Practice Address - Phone:507-383-3134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54799208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty