Provider Demographics
NPI:1144258849
Name:EDINA FAMILY PHYSICIANS
Entity type:Organization
Organization Name:EDINA FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMININSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:ODELL COWLES
Authorized Official - Suffix:
Authorized Official - Credentials:BSM, MA
Authorized Official - Phone:952-345-2210
Mailing Address - Street 1:5301 VERNON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2303
Mailing Address - Country:US
Mailing Address - Phone:952-925-2200
Mailing Address - Fax:952-925-3450
Practice Address - Street 1:5301 VERNON AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2303
Practice Address - Country:US
Practice Address - Phone:952-925-2200
Practice Address - Fax:952-925-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN148010300Medicaid
MN148010300Medicaid
MN0840730001Medicare NSC