Provider Demographics
NPI:1154381804
Name:SOUTHDALE ANESTHESIOLOGISTS, LLC
Entity type:Organization
Organization Name:SOUTHDALE ANESTHESIOLOGISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KLAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-924-5187
Mailing Address - Street 1:6401 FRANCE AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2104
Mailing Address - Country:US
Mailing Address - Phone:952-924-5187
Mailing Address - Fax:952-924-5137
Practice Address - Street 1:6401 FRANCE AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2104
Practice Address - Country:US
Practice Address - Phone:952-924-5187
Practice Address - Fax:952-924-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN058400200Medicaid
160412OtherUCARE MINNESOTA
WI32895100Medicaid
CH9609Medicare ID - Type UnspecifiedMEDICARE RAILROAD