Healthcare Provider Details

I. General information

NPI: 1972553741
Provider Name (Legal Business Name): MINNESOTA ORTHOPAEDIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8290 UNIVERSITY AVE NE SUITE 100
FRIDLEY MN
55432-1847
US

IV. Provider business mailing address

8290 UNIVERSITY AVE NE SUITE 100
FRIDLEY MN
55432-1847
US

V. Phone/Fax

Practice location:
  • Phone: 763-786-0461
  • Fax: 763-786-0471
Mailing address:
  • Phone: 763-717-4105
  • Fax: 952-456-7092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberHFID#04305
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER D HOLMBERG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 763-786-9543