Provider Demographics
NPI:1831162601
Name:SERVICE, GEOFFREY J (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:J
Last Name:SERVICE
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 1:2211 PARK AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3753
Mailing Address - Country:US
Mailing Address - Phone:612-871-1144
Mailing Address - Fax:612-871-2012
Practice Address - Street 1:2080 WOODWINDS DR STE 240
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2539
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:651-645-6166
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI73030-20207Y00000X
MN46856207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN659401800Medicaid
MNP00610300OtherMEDICARE RAILROAD
MNP00610300OtherMEDICARE RAILROAD
MN659401800Medicaid
MN127696Medicare UPIN