Healthcare Provider Details

I. General information

NPI: 1710921994
Provider Name (Legal Business Name): GAIL A RADOSEVICH RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD INTERNATIONAL DIABETES CENTER
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3393
  • Fax:
Mailing address:
  • Phone: 952-993-7169
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number1750
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: