Healthcare Provider Details

I. General information

NPI: 1760714133
Provider Name (Legal Business Name): ELIZABETH REISDORF RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

M HEALTH FAIRVIEW CLINIC-FRIDLEY 6341 UNIVERSITY AVE NE
FRIDLEY MN
55432
US

IV. Provider business mailing address

M HEALTH FAIRVIEW CLINIC-FRIDLEY 6341 UNIVERSITY AVE NE
FRIDLEY MN
55432
US

V. Phone/Fax

Practice location:
  • Phone: 763-572-5700
  • Fax: 763-568-5888
Mailing address:
  • Phone: 763-572-5700
  • Fax: 763-568-5888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2692
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: