Provider Demographics
NPI:1972553741
Name:MINNESOTA ORTHOPAEDIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MINNESOTA ORTHOPAEDIC SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-786-9543
Mailing Address - Street 1:8290 UNIVERSITY AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1847
Mailing Address - Country:US
Mailing Address - Phone:763-717-4105
Mailing Address - Fax:952-456-7092
Practice Address - Street 1:8290 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-1847
Practice Address - Country:US
Practice Address - Phone:763-786-0461
Practice Address - Fax:763-786-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNHFID#04305261QA1903X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN726170500Medicaid
MN490000028Medicare ID - Type Unspecified
MN3871660001Medicare NSC
MN726170500Medicaid