Healthcare Provider Details

I. General information

NPI: 1114610193
Provider Name (Legal Business Name): BRIAN JEFFREY SERBER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 XERXES AVE S
EDINA MN
55423-1033
US

IV. Provider business mailing address

8987 UNDERWOOD LN N
MAPLE GROVE MN
55369-6730
US

V. Phone/Fax

Practice location:
  • Phone: 952-925-8500
  • Fax:
Mailing address:
  • Phone: 612-805-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2844
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: