Provider Demographics
NPI:1790222438
Name:PLASTIC SURGERY CONSULTANTS
Entity Type:Organization
Organization Name:PLASTIC SURGERY CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-602-5326
Mailing Address - Street 1:3300 EDINBOROUGH WAY
Mailing Address - Street 2:STE 410
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5923
Mailing Address - Country:US
Mailing Address - Phone:952-746-6767
Mailing Address - Fax:952-746-6768
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:STE 110N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-602-5311
Practice Address - Fax:651-222-6786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA ONCOLOGY HEMATOLOGY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01828Medicare UPIN