Basic Information
| Provider Information | |||||||||
| NPI: | 1982783148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MINNESOTA RADIOLOGY INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7366 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563027366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202575595 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 E MAIN ST | ||||||||
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| City: | CROSBY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564411645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185467000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAUER | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2185467000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.