MEDICARE: CDI FAIRVIEW EDEN PRAIRIE 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	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1679512172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CDI FAIRVIEW EDEN PRAIRIE LLC

Provider Business Mailing Address
First Line	:	NW5765
Second Line	:	PO BOX 1450
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55485-5765
Country	:	US
Telephone Number	:	952-542-8553
Fax Number	:	952-513-6880

Provider Business Practice Location Address
First Line	:	775 PRAIRIE CENTER DR
Second Line	:	SUITE 260
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-7314
Country	:	US
Telephone Number	:	952-345-3805
Fax Number	:	952-294-8217

Authorized Official
Title or Position	:	OFFICER ON THE BOARD SECRETARY
Name	:	DONALD D JACOBSEN
Credential	:
Telephone Number	:	952-543-6500

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	08/22/2020

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