Provider Demographics
NPI:1538106521
Name:MONTICELLO-BIG LAKE ANESTHESIOLOGY
Entity type:Organization
Organization Name:MONTICELLO-BIG LAKE ANESTHESIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-271-2303
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:1013 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8575
Practice Address - Country:US
Practice Address - Phone:763-271-2303
Practice Address - Fax:763-295-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302G4MOOtherBLUE CROSS OF MN
MN111217OtherHEALTHPARTNERS
MN136709OtherUCARE/MANAGED CARE
MN136709OtherUCARE/MANAGED CARE
MNC03975Medicare ID - Type Unspecified