Healthcare Provider Details

I. General information

NPI: 1114962214
Provider Name (Legal Business Name): BARIATRIC SPECIALISTS OF MINNESOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SMITH AVE N
SAINT PAUL MN
55102-2393
US

IV. Provider business mailing address

310 SMITH AVE N
SAINT PAUL MN
55102-2383
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1665
License Number StateMN

VIII. Authorized Official

Name: DR. WILLIAM M RUPP
Title or Position: PARTNER
Credential: M.D.
Phone: 651-227-6351