Provider Demographics
NPI:1831478940
Name:MINNESOTA GYNECOLOGY AND AESTHETICS, PA
Entity type:Organization
Organization Name:MINNESOTA GYNECOLOGY AND AESTHETICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:N
Authorized Official - Last Name:ERHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-220-9301
Mailing Address - Street 1:1421 EAST WAYZATA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1939
Mailing Address - Country:US
Mailing Address - Phone:952-473-6642
Mailing Address - Fax:952-473-2312
Practice Address - Street 1:1421 EAST WAYZATA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1939
Practice Address - Country:US
Practice Address - Phone:952-473-6642
Practice Address - Fax:952-473-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33512261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN615323200Medicaid
MN615323200Medicaid