Healthcare Provider Details

I. General information

NPI: 1437459211
Provider Name (Legal Business Name): EDEN PRAIRIE CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9358 ENSIGN AVE S SUITE C
BLOOMINGTON MN
55438-1472
US

IV. Provider business mailing address

9358 ENSIGN AVE S SUITE C
BLOOMINGTON MN
55438-1472
US

V. Phone/Fax

Practice location:
  • Phone: 952-944-6989
  • Fax:
Mailing address:
  • Phone: 952-944-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: RADHA KRISHNA KUMAR
Title or Position: OWNER
Credential: M.D.
Phone: 952-944-6989