MEDICARE: MINNEAPOLIS PLASTIC SURGERY LTD

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	2086S0122X	Plastic and Reconstructive Surgery Physician	788	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9813016	OTHER	MN	MEDICA INS CLINIC

General Provider Information

NPI Number	:	1730156274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNEAPOLIS PLASTIC SURGERY LTD

Provider Business Mailing Address
First Line	:	4825 OLSON MEMORIAL HWY
Second Line	:	#200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55422
Country	:	US
Telephone Number	:	763-545-0443
Fax Number	:	763-545-2784

Provider Business Practice Location Address
First Line	:	4825 OLSON MEMORIAL HWY
Second Line	:	#200
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55422
Country	:	US
Telephone Number	:	763-545-0443
Fax Number	:	763-545-2784

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD H THOLEN
Credential	:	MD
Telephone Number	:	763-545-0443

Provider Enumeration Date	:	03/03/2006
Last Update Date	:	08/22/2020

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