Provider Demographics
NPI:1174554653
Name:MINNESOTA VASCULAR CLINIC, PLLC
Entity type:Organization
Organization Name:MINNESOTA VASCULAR CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-837-9700
Mailing Address - Street 1:4570 W 77TH ST
Mailing Address - Street 2:SUITE 235
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6405 FRANCE AVE S
Practice Address - Street 2:SUITE W440
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2163
Practice Address - Country:US
Practice Address - Phone:952-927-7004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1655261QR0200X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03939Medicare ID - Type Unspecified