Provider Demographics
NPI:1871679456
Name:ROSEAU/WARROAD EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:ROSEAU/WARROAD EYE CLINIC, P.A.
Other - Org Name:ERICKSON DIETER OPTOMETRISTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-463-2020
Mailing Address - Street 1:306 N MAIN
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751
Mailing Address - Country:US
Mailing Address - Phone:218-463-2020
Mailing Address - Fax:218-463-2055
Practice Address - Street 1:306 N MAIN
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751
Practice Address - Country:US
Practice Address - Phone:218-463-2020
Practice Address - Fax:218-463-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1618152W00000X
MN1693152W00000X
MN2946152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13951OtherBLUE CROSS BLUE SHIELD
MN844323800Medicaid
MNHP42709OtherHEALTHPARTNERS
MN13962OtherBLUE CROSS BLUE SHIELD
MN275823700Medicaid
MN192K5YEOtherBLUE CROSS BLUE SHIELD
MN295457500Medicaid
MNHP40537OtherHEALTHPARTNERS
MNU98041Medicare UPIN
MN275823700Medicaid
MN419000100Medicare PIN
MNT65490Medicare UPIN
MNHP40537OtherHEALTHPARTNERS
MN295457500Medicaid
MN410002093Medicare PIN