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

Last updated

Feb 17, 2025By the provider in NPPES

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

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Merlin Emery Brown, MD

  • Internal Medicine Physician
  • Edina, MN
  • NPI 1053317354
  Medicare reassignment Care Compare group NPD
• Vicki I Buth, CNP

  • Obstetrics & Gynecology Nurse Practitioner
  • Edina, MN
  • NPI 1013982180
  Medicare reassignment Care Compare group NPD
• Ashley Paige Willette, CNP

  • Primary Care Nurse Practitioner
  • Edina, MN
  • NPI 1144026824
  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": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_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 (Edina Specialty Surgery Center)
• Southwest Home Health Care LLC
• Southwest Surgical Center LLC (Orthopaedic Institute Surgery Center)

• Internal Medicine Physician in Edina, MN
• Providers in Edina, MN by specialty
• 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.