Provider Demographics
NPI:1881815322
Name:MARK C ENGASSER M D P A
Entity Type:Organization
Organization Name:MARK C ENGASSER M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ENGASSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-920-4333
Mailing Address - Street 1:6600 FRANCE AVE S
Mailing Address - Street 2:SUITE 615
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1807
Mailing Address - Country:US
Mailing Address - Phone:952-920-4333
Mailing Address - Fax:952-920-6338
Practice Address - Street 1:6600 FRANCE AVE S
Practice Address - Street 2:SUITE 615
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1807
Practice Address - Country:US
Practice Address - Phone:952-920-4333
Practice Address - Fax:952-920-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22841207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN856500700Medicaid
MNC03813Medicare ID - Type Unspecified
MN856500700Medicaid