=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144221698
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD D EISER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 12/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 17TH AVE E
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308-3703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-762-6040
-----------------------------------------------------
Fax | 320-762-6038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5775 WAYZATA BLVD SUITE 400
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-762-6040
-----------------------------------------------------
Fax | 320-762-6038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 21290
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------