Provider Demographics
NPI:1801946223
Name:PREMIER OBGYN OF MINNESOTA PLLC
Entity type:Organization
Organization Name:PREMIER OBGYN OF MINNESOTA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR MGR CRED IMPL AND PROVIDER SERV
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-486-8439
Mailing Address - Street 1:3625 W. 65TH STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-920-7001
Mailing Address - Fax:952-345-0472
Practice Address - Street 1:3625 W. 65TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-920-7001
Practice Address - Fax:952-345-0472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN005416207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN755010300Medicaid
MNC00177Medicare ID - Type UnspecifiedMEDICARE CLINIC ID