Provider Demographics
NPI:1568503845
Name:MINNESOTA VASCULAR SURGERY CENTER
Entity type:Organization
Organization Name:MINNESOTA VASCULAR SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:NORBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-398-2203
Mailing Address - Street 1:600 COUNTY ROAD D
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3519
Mailing Address - Country:US
Mailing Address - Phone:763-432-4300
Mailing Address - Fax:763-432-4301
Practice Address - Street 1:600 COUNTY ROAD D
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-3519
Practice Address - Country:US
Practice Address - Phone:763-432-4300
Practice Address - Fax:763-432-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN508958000Medicaid
MN508958000Medicaid