Provider Demographics
NPI:1891783965
Name:VITREO RETINAL SURGERY PLLC
Entity type:Organization
Organization Name:VITREO RETINAL SURGERY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:POFFENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-897-1175
Mailing Address - Street 1:3601 W 76TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-3004
Mailing Address - Country:US
Mailing Address - Phone:952-929-1131
Mailing Address - Fax:952-897-1178
Practice Address - Street 1:3601 W 76TH ST STE 300
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-6215
Practice Address - Country:US
Practice Address - Phone:952-929-1131
Practice Address - Fax:952-897-1178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Single Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN27420RAOtherBCBS
MN27420RAOtherBCBS