Healthcare Provider Details

I. General information

NPI: 1952380677
Provider Name (Legal Business Name): MARY T SPADES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD METHODIST HOSPITAL
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

4501 GOLF TER
EDINA MN
55424-1510
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-5222
  • Fax: 952-993-6499
Mailing address:
  • Phone: 952-925-1793
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 118777-3
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0357
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: