Healthcare Provider Details

I. General information

NPI: 1174554653
Provider Name (Legal Business Name): MINNESOTA VASCULAR CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 FRANCE AVE S SUITE W440
EDINA MN
55435-2163
US

IV. Provider business mailing address

4570 W 77TH ST SUITE 235
EDINA MN
55435-5008
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-7004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number1655
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number1655
License Number StateMN

VIII. Authorized Official

Name: DR. ANDREW CRAGG
Title or Position: SHAREHOLDER
Credential: M.D.
Phone: 952-837-9700