Healthcare Provider Details

I. General information

NPI: 1083679484
Provider Name (Legal Business Name): ST. PAUL SURGEONS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BEAM AVE STE 302
MAPLEWOOD MN
55109-1163
US

IV. Provider business mailing address

1655 BEAM AVE STE 302
MAPLEWOOD MN
55109-1163
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-6351
  • Fax: 651-227-1134
Mailing address:
  • Phone: 651-227-6351
  • Fax: 651-227-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number53
License Number StateMN

VIII. Authorized Official

Name: DR. PETER H KELLY
Title or Position: PARTNER
Credential: M.D.
Phone: 651-227-6351