Provider Demographics
NPI:1215059878
Name:MINNESOTA NEUROVASCULAR & SKULL BASE SURGERY
Entity type:Organization
Organization Name:MINNESOTA NEUROVASCULAR & SKULL BASE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:S
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-374-0177
Mailing Address - Street 1:3901 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3803
Mailing Address - Country:US
Mailing Address - Phone:952-285-1016
Mailing Address - Fax:952-285-1018
Practice Address - Street 1:3033 EXCELSIOR BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4688
Practice Address - Country:US
Practice Address - Phone:612-374-0177
Practice Address - Fax:612-374-0893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD77007040Medicaid
WI21266300Medicaid
SD77007040Medicaid