Healthcare Provider Details

I. General information

NPI: 1184151524
Provider Name (Legal Business Name): SAMUEL W CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 65TH ST
EDINA MN
55435-1706
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7000
  • Fax: 952-456-7001
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number64069
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number64069
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: