=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497766471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDINA PLASTIC SURGERY, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 09/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6525 FRANCE AVE. S., SUITE 300
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-925-1765
-----------------------------------------------------
Fax | 952-925-1579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6525 FRANCE AVE. S., SUITE 300
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-925-1765
-----------------------------------------------------
Fax | 952-925-1579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGEON
-----------------------------------------------------
Name | ROBERT C. WILKE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 952-925-1765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------