Healthcare Provider Details

I. General information

NPI: 1578850046
Provider Name (Legal Business Name): BRIAN EDMONSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 AMERICAN BLVD W STE 200
BLOOMINGTON MN
55431-4420
US

IV. Provider business mailing address

3800 AMERICAN BLVD W STE 200
BLOOMINGTON MN
55431-4420
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax: 952-831-1626
Mailing address:
  • Phone: 952-831-8742
  • Fax: 952-831-1626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number9381
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8711
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: