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General NPI Number Information
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NPI Number | 1720574445
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Entity Type | Organization
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Legal Business Name | ECHELON SURGICAL SPECIALISTS LLC
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Dates
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Enumeration Date | 07/05/2018
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 15450 HIGHWAY 7 STE 225
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City | MINNETONKA
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State | MN
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Zip | 55345-3522
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Country | US
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Telephone | 507-383-3134
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Fax |
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Provider Business Mailing Address
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Address Line | 12300 168TH ST W
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City | LAKEVILLE
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State | MN
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Zip | 55044-9224
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Country | US
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Telephone | 507-383-3134
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. MATTHEW CARROLL CAMP
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Credential | M.D.
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Telephone | 507-383-3134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 54799
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License Number State | MN
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