=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215921408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-MINNESOTA RADIATION ONCOLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2005
-----------------------------------------------------
Last Update Date | 10/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6950 FRANCE AVE S #200
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-920-4915
-----------------------------------------------------
Fax | 952-915-6091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6950 FRANCE AVE S #200
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-920-4915
-----------------------------------------------------
Fax | 952-915-6091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT E HASELOW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 952-920-4915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 1559
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------