Healthcare Provider Details

I. General information

NPI: 1841248291
Provider Name (Legal Business Name): SURGICAL SPECIALISTS OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 CHICAGO AVE SUITE 601
MINNEAPOLIS MN
55404-4522
US

IV. Provider business mailing address

2545 CHICAGO AVE SUITE 601
MINNEAPOLIS MN
55404-4522
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-7770
  • Fax: 612-863-7772
Mailing address:
  • Phone: 612-863-7770
  • Fax: 612-863-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ERIC M JOHNSON
Title or Position: PRESIDENT
Credential: MD
Phone: 612-863-7770