Healthcare Provider Details

I. General information

NPI: 1114124971
Provider Name (Legal Business Name): EDINA EYE PHYSICIANS AND SURGEONS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11855 ULYSSES ST SUITE 140
BLAINE MN
55434
US

IV. Provider business mailing address

3777 COON RAPIDS BLVD NW STE 100
COON RAPIDS MN
55433-2630
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-7420
  • Fax: 763-421-0730
Mailing address:
  • Phone: 612-999-2020
  • Fax: 763-421-0730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: DELTA JORGENSEN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 763-592-8413