Provider Demographics
NPI:1922009471
Name:MINNESOTA DIAGNOSTIC IMAGING PARTNERS, LLC
Entity Type:Organization
Organization Name:MINNESOTA DIAGNOSTIC IMAGING PARTNERS, LLC
Other - Org Name:MAPLE GROVE IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-398-2207
Mailing Address - Street 1:9855 HOSPITAL DRIVE
Mailing Address - Street 2:#150
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4776
Mailing Address - Country:US
Mailing Address - Phone:763-559-2171
Mailing Address - Fax:763-398-6364
Practice Address - Street 1:9855 HOSPITAL DRIVE
Practice Address - Street 2:#105
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4776
Practice Address - Country:US
Practice Address - Phone:763-559-2171
Practice Address - Fax:763-398-4401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA DIAGNOSTIC IMAGING PARTNERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-09
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN420012800Medicaid
342S2MIOtherBCBS
1601988OtherMEDICA
4700000029Medicare UPIN
MN420012800Medicaid