NPIMap

Organization Active NPI

Blaine Eye Clinic Optometrists, P.a.

  • Durable Medical Equipment & Medical Supplies
  • Blaine, MN
National Provider Identifier
1043363401
Registry record updated Feb 15, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X
Legal business name
BLAINE EYE CLINIC OPTOMETRISTS, P.A.
Practice address
12170 Aberdeen St NE
Blaine, MN 55449-4716
Phone
(763) 757-7000
Fax
(763) 757-3328
NPI assigned
Jan 19, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 15, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lynn Alan Sulerud, O.D.
Title
Owner
Phone
(763) 757-7000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X SINGLE SPECIALTY GROUP 152W00000X MN
Durable Medical Equipment & Medical Supplies 332B00000X MN Primary

Addresses

Primary practice location

12170 Aberdeen St NE
Blaine, MN 55449-4716

Mailing address

12170 Aberdeen St NE
Blaine, MN 55449-4716
Phone (763) 757-7000

Other identifiers 2

IdentifierTypeStateIssuer
DB3402OtherMNRAILROAD MEDICARE
221526800MedicaidMN

Other names 1

  • Blaine Eye Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050408000253 MN Part B Supplier - Clinic/Group Practice 2264479575 Receives reassigned benefits from 8 practitioners
Practice locations: Blaine, MN
O20100930059429 MN DME Supplier - Physician - OptometristDME Supplier - Optician 2264479575 Practice locations: Blaine, MN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2228198Blaine Eye Clinic12170 Aberdeen St NE, Blaine, MN 55449Certificate of waiverJun 22, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Blaine Eye Clinic12170 Aberdeen St NE, Blaine, MN 55449-4716(763) 757-7000 Prosthetic Lenses: Conventional Eyeglasses|Prosthetic Lenses: Conventional Contact Lenses|Prosthetic Lenses: Prosthetics Cataract Lenses Accepts assignmentParticipating since Oct 1, 1984

National Provider Directory

National Provider Directory

Locations

12170 Aberdeen St NE
Minneapolis, MN 55449
Phone (763) 757-7000

11901 Highway 65 NE
Minneapolis, MN 55434
Phone (763) 404-6244

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169164800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1297728000000",
    "number": "1043363401",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12170 ABERDEEN ST NE",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554494716",
            "telephone_number": "763-757-7000",
            "fax_number": "763-757-3328"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12170 ABERDEEN ST NE",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554494716",
            "telephone_number": "763-757-7000",
            "fax_number": "763-757-3328"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLAINE EYE CLINIC OPTOMETRISTS, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-19",
        "last_updated": "2011-02-15",
        "status": "A",
        "authorized_official_last_name": "SULERUD",
        "authorized_official_first_name": "LYNN",
        "authorized_official_middle_name": "ALAN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "763-757-7000",
        "authorized_official_credential": "O.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "MN",
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "MN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DB3402",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "221526800",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Blaine Eye Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Blaine, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.