MEDICARE: NORTH MEMORIAL AMBULATORY SURGERY CENTER AT MAPLE GROVE, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053442	OTHER		PREFERRED ONE
2	1316133044	OTHER	MN	UCARE
3	227637	OTHER		HEALTH PARTNERS
4	68-00092	OTHER		PATIENT CHOICE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	68-00092	OTHER		SELECTCARE
7	68-00092	OTHER		LABORCARE
8	68-00092	OTHER		MEDICA
9	5T43MA	OTHER	MN	BSMN

General Provider Information

NPI Number	:	1316133044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH MEMORIAL AMBULATORY SURGERY CENTER AT MAPLE GROVE, LLC

Provider Business Mailing Address
First Line	:	9855 HOSPITAL DR
Second Line	:	STE 175
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-4772
Country	:	US
Telephone Number	:	763-981-3200
Fax Number	:

Provider Business Practice Location Address
First Line	:	9855 HOSPITAL DR
Second Line	:	STE 175
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-4772
Country	:	US
Telephone Number	:	763-981-3200
Fax Number	:	763-981-3201

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. STEVEN J. KERN
Credential	:	M.D.
Telephone Number	:	763-981-3200

Provider Enumeration Date	:	09/17/2007
Last Update Date	:	06/21/2018

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