Provider Demographics
NPI:1558326942
Name:SOUTHEAST MINNESOTA SPORTS MEDICINE & ORTHOPAEDIC SURGERY SPECIALISTS
Entity type:Organization
Organization Name:SOUTHEAST MINNESOTA SPORTS MEDICINE & ORTHOPAEDIC SURGERY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROMEYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-474-9300
Mailing Address - Street 1:111 RIVERFRONT
Mailing Address - Street 2:STE 307
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3456
Mailing Address - Country:US
Mailing Address - Phone:507-474-9300
Mailing Address - Fax:507-474-9302
Practice Address - Street 1:111 RIVERFRONT
Practice Address - Street 2:STE 307
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3456
Practice Address - Country:US
Practice Address - Phone:507-474-9300
Practice Address - Fax:507-474-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04010Medicare ID - Type Unspecified