Provider Demographics
NPI:1407059678
Name:SOUTH SUBURBAN EYECARE SPECIALISTS PA
Entity type:Organization
Organization Name:SOUTH SUBURBAN EYECARE SPECIALISTS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-898-9588
Mailing Address - Street 1:17690 KENWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9764
Mailing Address - Country:US
Mailing Address - Phone:952-898-9588
Mailing Address - Fax:952-898-2030
Practice Address - Street 1:17690 KENWOOD TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9764
Practice Address - Country:US
Practice Address - Phone:952-898-9588
Practice Address - Fax:952-898-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN176625200Medicaid
MN499R7LAOtherBLUE CROSS BLUE SHIELD MN
MN2203175OtherUNITED HEALTH CARE
MN79G34LAOtherBLUE PLUS
MN113428OtherHEALTH PARTNERS
MN2203175OtherMEDICA
MN2203175OtherSELECT CARE
MNA61971031584OtherPREFERRED ONE
MN=========OtherAETNA
MN=========OtherPATIENTS CHOICE WASSAU
MN=========OtherCIGNA
MN2203175OtherUNITED HEALTH CARE
MNA61971031584OtherPREFERRED ONE
MN=========OtherVSP