Healthcare Provider Details

I. General information

NPI: 1083661680
Provider Name (Legal Business Name): BRUCE IRA IDELKOPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST SUITE 150
EDINA MN
55435-2109
US

IV. Provider business mailing address

3400 W 66TH ST SUITE 150
EDINA MN
55435-2109
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-7200
  • Fax: 763-302-4234
Mailing address:
  • Phone: 952-920-7200
  • Fax: 763-302-4234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number22536
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: