Provider Demographics
NPI:1750498465
Name:MINNEAPOLIS MEDICAL EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:MINNEAPOLIS MEDICAL EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-871-3611
Mailing Address - Street 1:710 E 24TH ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3840
Mailing Address - Country:US
Mailing Address - Phone:612-871-3611
Mailing Address - Fax:612-871-7294
Practice Address - Street 1:710 E 24TH ST
Practice Address - Street 2:SUITE 402
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3840
Practice Address - Country:US
Practice Address - Phone:612-871-3611
Practice Address - Fax:612-871-7294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN008808100Medicaid
C01550Medicare PIN