Healthcare Provider Details

I. General information

NPI: 1790222438
Provider Name (Legal Business Name): PLASTIC SURGERY CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 110N
SAINT PAUL MN
55114-1052
US

IV. Provider business mailing address

3300 EDINBOROUGH WAY STE 410
EDINA MN
55435-5923
US

V. Phone/Fax

Practice location:
  • Phone: 651-602-5311
  • Fax: 651-222-6786
Mailing address:
  • Phone: 952-746-6767
  • Fax: 952-746-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateMN

VIII. Authorized Official

Name: JOAN L THEIS
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 651-602-5326