Healthcare Provider Details

I. General information

NPI: 1962479071
Provider Name (Legal Business Name): RUSSELL L WAVRIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S STE 540
EDINA MN
55435-2131
US

IV. Provider business mailing address

6545 FRANCE AVE S STE 540
EDINA MN
55435-2131
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-4045
  • Fax: 952-924-4133
Mailing address:
  • Phone: 952-927-4045
  • Fax: 952-924-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number244196
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number244196
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: