Healthcare Provider Details

I. General information

NPI: 1376596775
Provider Name (Legal Business Name): COLON & RECTAL SURGERY ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BROADWAY ST NE SUITE 115
MINNEAPOLIS MN
55413-1740
US

IV. Provider business mailing address

3433 BROADWAY ST NE SUITE 115
MINNEAPOLIS MN
55413-1740
US

V. Phone/Fax

Practice location:
  • Phone: 651-312-1500
  • Fax: 651-312-1570
Mailing address:
  • Phone: 651-312-1500
  • Fax: 651-312-1570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number567
License Number StateMN

VIII. Authorized Official

Name: DR. MICHAEL PAUL SPENCER
Title or Position: PRESIDENT CEO
Credential: MD
Phone: 651-312-1500