MEDICARE: MINNESOTA CENTER FOR OBESITY, METABOLISM & ENDOCRINOLOGY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1591	MN
2	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	1591	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DB4333	OTHER	MN	RR MEDICARE
6	C03334	OTHER	MN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	96386	OTHER	MN	HEALTHPARTNERS
4	165867H314	OTHER	MN	UCARE
5	547S0MI	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1164477709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA CENTER FOR OBESITY, METABOLISM & ENDOCRINOLOGY, PA

Provider Business Mailing Address
First Line	:	1185 TOWN CENTRE DR
Second Line	:	SUITE 220
City	:	EAGAN
State	:	MN
Zip	:	55123-1187
Country	:	US
Telephone Number	:	651-379-1600
Fax Number	:	651-379-1650

Provider Business Practice Location Address
First Line	:	1185 TOWN CENTRE DR
Second Line	:	SUITE 220
City	:	EAGAN
State	:	MN
Zip	:	55123-1187
Country	:	US
Telephone Number	:	651-379-1600
Fax Number	:	651-379-1650

Authorized Official
Title or Position	:	COO
Name	:	REBECCA GONZALEZ-CAMPOY
Credential	:
Telephone Number	:	651-379-1600

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	02/06/2013

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