Healthcare Provider Details

I. General information

NPI: 1720274467
Provider Name (Legal Business Name): NORTH MEMORIAL ENDOSCOPY CENTER AT MAPLE GROVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9855 HOSPITAL DR SUITE 275
MAPLE GROVE MN
55369-4778
US

IV. Provider business mailing address

9855 HOSPITAL DR SUITE 275
MAPLE GROVE MN
55369-4778
US

V. Phone/Fax

Practice location:
  • Phone: 763-981-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GREG MEVISSEN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 763-981-3200