Healthcare Provider Details

I. General information

NPI: 1285610113
Provider Name (Legal Business Name): DONALD M ROOS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAKE DR E PARK NICOLLET CLINIC URGENT CARE
CHANHASSEN MN
55317
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-4300
  • Fax:
Mailing address:
  • Phone: 952-993-7169
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22638
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: