Healthcare Provider Details

I. General information

NPI: 1831357433
Provider Name (Legal Business Name): EDINA MN OPHTHALMOLOGY ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3124 W 70TH ST
EDINA MN
55435-4227
US

IV. Provider business mailing address

3124 W 70TH ST
EDINA MN
55435-4227
US

V. Phone/Fax

Practice location:
  • Phone: 952-848-8338
  • Fax: 952-848-8302
Mailing address:
  • Phone: 952-848-8338
  • Fax: 952-848-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. BILLIE A PAYNE
Title or Position: PRESIDENT
Credential:
Phone: 615-665-1283