=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841248291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL SPECIALISTS OF MINNESOTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 06/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2545 CHICAGO AVE SUITE 601
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55404-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-863-7770
-----------------------------------------------------
Fax | 612-863-7772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2545 CHICAGO AVE SUITE 601
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55404-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-863-7770
-----------------------------------------------------
Fax | 612-863-7772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ERIC M JOHNSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 612-863-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------