Healthcare Provider Details

I. General information

NPI: 1124072673
Provider Name (Legal Business Name): PEDIATRIC RADIOLOGY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

PO BOX 46100
PLYMOUTH MN
55446-0100
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-8200
  • Fax:
Mailing address:
  • Phone: 763-553-9920
  • Fax: 763-553-9910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LELAND PREWITT JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 612-813-8200