Healthcare Provider Details

I. General information

NPI: 1295910412
Provider Name (Legal Business Name): PLASTIC SURGERY SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 FRANCE AVE S SUITE 510
EDINA MN
55435-4534
US

IV. Provider business mailing address

7373 FRANCE AVE S SUITE 510
EDINA MN
55435-4534
US

V. Phone/Fax

Practice location:
  • Phone: 952-830-1028
  • Fax: 952-830-0091
Mailing address:
  • Phone: 952-830-1028
  • Fax: 952-830-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25914
License Number StateMN

VIII. Authorized Official

Name: DR. ALLEN LESTER VAN BEEK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 952-830-1028