Southdale Physicians, LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

SOUTHDALE PHYSICIANS, LLC

Practice address

6565 France Ave S Ste 350
Edina, MN 55435-2137

Phone

(612) 430-8120

NPI assigned

Mar 9, 2017

Organization subpart

No

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

Authorized official

Name

Derek J Dagendesh

Title

Office Administrator

Phone

(952) 999-4049

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

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

CLIA laboratory certificates

Locations

Practitioners 3

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

• Merlin Emery Brown, MD

  • Internal Medicine Physician
  • Edina, MN
  • NPI 1053317354

  Internal Medicine, MN

  Medicare reassignment Care Compare group NPD
• Vicki I Buth, CNP

  • Obstetrics & Gynecology Nurse Practitioner
  • Edina, MN
  • NPI 1013982180

  MN

  Medicare reassignment Care Compare group NPD
• Ashley Paige Willette, CNP

  • Primary Care Nurse Practitioner
  • Edina, MN
  • NPI 1144026824

  MN

  Medicare reassignment NPD

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

{
    "created_epoch": "1489017600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739750400000",
    "number": "1124569249",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6565 FRANCE AVE S STE 350",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352137"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6565 FRANCE AVE S STE 350",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352137",
            "telephone_number": "612-430-8120"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHDALE PHYSICIANS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-09",
        "last_updated": "2025-02-17",
        "certification_date": "2025-02-17",
        "status": "A",
        "authorized_official_last_name": "DAGENDESH",
        "authorized_official_first_name": "DEREK",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OFFICE ADMINISTRATOR",
        "authorized_official_telephone_number": "952-999-4049"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Southdale Optical Co
• Southdale Otolaryngology PA
• Southdale Pediatric Associates, LTD
• Southdale Periodontics
• Southdale Periodontics, PLLC
• Southdale Specialty Surgery Center, LLC
• Southdale Transportation Services, Inc.
• Southhealth ASC, LLC
• Southwest Home Health Care LLC
• Southwest Surgical Center LLC

• All providers in Edina, MN
• Internal Medicine Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2025; 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.