Active NPI
Northwest Eye Clinic, LLC
- Ophthalmology Physician
- Maple Grove, MN
National Provider Identifier
1164508917
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Ophthalmology Physician
- License
- 360
- Legal business name
- NORTHWEST EYE CLINIC, LLC
- Practice address
- 12000 Elm Creek Blvd N Ste 100
Maple Grove, MN 55369-7074 - Phone
- (763) 416-7600
- Fax
- (763) 416-7634
- NPI assigned
- Oct 27, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Kelly Pettengill
- Title
- Credentialing and Data Management
- Phone
- (763) 416-7629
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ophthalmology Physician | 207W00000X | 360 | MN | Primary |
Addresses
Primary practice location
12000 Elm Creek Blvd N Ste 100
Maple Grove, MN 55369-7074
Mailing address
8401 Golden Valley Rd Ste 330
Golden Valley, MN 55427-4488
Phone (763) 416-7629
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 221967100 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040204000843 | MN | Part B Supplier - Clinic/Group Practice | 2163315045 |
Receives reassigned benefits from 22 practitioners 7 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Saint Anthony, MN; Woodbury, MN; Wayzata, MN; St Anthony, MN; Minnetonka, MN; Maple Grove, MN; Golden Valley, MN |
Other NPIs on the same Medicare enrollment 7
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider DirectoryInteroperability endpoints
- https://api.platform.athenahealth.com/1964/brand/1/csg/25/fhir/r4
Practitioners & affiliated clinicians
Practitioners 1
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": "1161907200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1584489600000",
"number": "1164508917",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8401 GOLDEN VALLEY RD STE 330",
"city": "GOLDEN VALLEY",
"state": "MN",
"postal_code": "554274488",
"telephone_number": "763-416-7629",
"fax_number": "763-383-4147"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12000 ELM CREEK BLVD N STE 100",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553697074",
"telephone_number": "763-416-7600",
"fax_number": "763-416-7634"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "NORTHWEST EYE CLINIC, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-10-27",
"last_updated": "2020-03-18",
"certification_date": "2020-03-18",
"status": "A",
"authorized_official_last_name": "PETTENGILL",
"authorized_official_first_name": "KELLY",
"authorized_official_title_or_position": "CREDENTIALING AND DATA MANAGEMENT",
"authorized_official_telephone_number": "763-416-7629"
},
"taxonomies": [
{
"code": "207W00000X",
"taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"desc": "Ophthalmology",
"state": "MN",
"license": "360",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "221967100",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Maple Grove, MN
- Northland Dental Partners, PLLC
- Elizabeth Michelle Northquest
- Northstar Neurological Clinic LTD
- Northstar Neurological Clinic, P.a.
- Northwest Compassionate Care, LLC
- Northwest Family Chiropractic PA
- Northwood Chiropractic & Wellness LLC
- Katelyn Jane Norwood, LPCC, NCC
- Amanda Kaye Nosbush
- Novacare Outpatient Rehabilitation East, Inc.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.