Provider Demographics
NPI:1003949892
Name:INFECTIOUS DISEASE CONSULTANTS PA
Entity type:Organization
Organization Name:INFECTIOUS DISEASE CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-746-8360
Mailing Address - Street 1:11676 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2009
Mailing Address - Country:US
Mailing Address - Phone:952-746-8360
Mailing Address - Fax:952-746-8368
Practice Address - Street 1:11676 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2009
Practice Address - Country:US
Practice Address - Phone:952-746-8360
Practice Address - Fax:952-746-8368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO0011OtherRAILROAD MEDICARE
MN533313000Medicaid
MNCO0011OtherRAILROAD MEDICARE