Healthcare Provider Details

I. General information

NPI: 1053344788
Provider Name (Legal Business Name): ST PAUL RHEUMATOLOGY P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2854 HIGHWAY 55 SUITE 190
EAGAN MN
55121-2156
US

IV. Provider business mailing address

2854 HIGHWAY 55 SUITE 190
EAGAN MN
55121-2156
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-4277
  • Fax:
Mailing address:
  • Phone: 651-644-4277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID J RIDLEY
Title or Position: OWNER
Credential: M.D.
Phone: 651-644-4277