Provider Demographics
NPI:1962493643
Name:MEDINI, EITAN (MD)
Entity Type:Individual
Prefix:
First Name:EITAN
Middle Name:
Last Name:MEDINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRA CARE CIR #1600
Mailing Address - Street 2:CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-229-4901
Mailing Address - Fax:320-229-5160
Practice Address - Street 1:1900 CENTRA CARE CIR #1600
Practice Address - Street 2:CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-229-4901
Practice Address - Fax:320-229-5160
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN218662085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1027482OtherPREFERRED ONE
512RIMEOtherBLUE CROSS BLUE SHIELD
COMPOtherFIRST HEALTH PLAN
COMPOtherMMSI
315JOMEOtherBLUE CROSS BLUE SHIELD
978660OtherARAZ GROUP AMERICAS PPO
2400101OtherMEDICA HEALTH PLANS
MN252563100Medicaid
COMPOtherONE HEALTH PLAN GREAT WES
127789OtherU CARE
COMPOtherCHAMPUS
HP33037OtherHEALTH PARTNERS
MN252563100Medicaid
COMPOtherFIRST HEALTH PLAN