Healthcare Provider Details

I. General information

NPI: 1770547317
Provider Name (Legal Business Name): PAUL LARSON OB GYN CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 FRANCE AVE S STE 100
EDINA MN
55435-3624
US

IV. Provider business mailing address

6525 FRANCE AVE S STE 100
EDINA MN
55435-2158
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-4021
  • Fax: 952-285-6183
Mailing address:
  • Phone: 952-927-4021
  • Fax: 952-285-6183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VC0200X
TaxonomyCritical Care Medicine (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTIN L. IMMERMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 952-927-4021