Healthcare Provider Details

I. General information

NPI: 1669496345
Provider Name (Legal Business Name): MNGI ENDOSCOPY ASC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADWAY ST NE STE 500
MINNEAPOLIS MN
55413
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax: 612-870-5491
Mailing address:
  • Phone: 612-871-1145
  • Fax: 612-870-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SCOTT KETOVER
Title or Position: PRESIDENT
Credential: MD
Phone: 612-871-1145