=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346468253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRVIEW MAPLE GROVE SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 02/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14500 99TH AVENUE NORTH
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-898-1424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 UNIVERSITY AVE W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-672-6740
-----------------------------------------------------
Fax | 612-884-3592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SYS DIR GOVT REIMB & NETWK REL
-----------------------------------------------------
Name | MAUREEN V RING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-672-6740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------