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General NPI Number Information
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NPI Number | 1124569249
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Entity Type | Organization
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Legal Business Name | SOUTHDALE PHYSICIANS, LLC
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Dates
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Enumeration Date | 03/09/2017
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 6565 FRANCE AVE S STE 350
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City | EDINA
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State | MN
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Zip | 55435-2137
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Country | US
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Telephone | 612-430-8120
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Fax |
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Provider Business Mailing Address
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Address Line | 6565 FRANCE AVE S STE 350
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City | EDINA
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State | MN
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Zip | 55435-2137
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | DEREK J DAGENDESH
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Credential |
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Telephone | 952-999-4049
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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