Healthcare Provider Details

I. General information

NPI: 1497766471
Provider Name (Legal Business Name): EDINA PLASTIC SURGERY, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 FRANCE AVE. S., SUITE 300
EDINA MN
55435
US

IV. Provider business mailing address

6525 FRANCE AVE. S., SUITE 300
EDINA MN
55435
US

V. Phone/Fax

Practice location:
  • Phone: 952-925-1765
  • Fax: 952-925-1579
Mailing address:
  • Phone: 952-925-1765
  • Fax: 952-925-1579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT C. WILKE
Title or Position: SURGEON
Credential: M.D.
Phone: 952-925-1765