Provider Demographics
NPI:1245305895
Name:SOUTHDALE PEDIATRIC ASSOCIATES, LTD
Entity type:Organization
Organization Name:SOUTHDALE PEDIATRIC ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-831-1944
Mailing Address - Street 1:3955 PARKLAWN AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5655
Mailing Address - Country:US
Mailing Address - Phone:952-831-1944
Mailing Address - Fax:952-278-6947
Practice Address - Street 1:3955 PARKLAWN AVE
Practice Address - Street 2:STE 120
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5655
Practice Address - Country:US
Practice Address - Phone:952-831-1944
Practice Address - Fax:952-278-6947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN196261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO1219Medicare ID - Type Unspecified