NPIMap

Organization Active NPI

Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • St. Anthony, MN
National Provider Identifier
1255417002
Registry record updated Mar 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
360 Issued in MN
Legal business name
NORTHWEST EYE CLINIC, LLC
Practice address
2601 39TH Ave NE Ste 1
St. Anthony, MN 55421
Phone
(763) 416-7600
Fax
(763) 416-7634
NPI assigned
Oct 27, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 18, 2020

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)CodeLicenseStatePrimary
Ophthalmology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207W00000X 360 MN Primary

Addresses

Primary practice location

2601 39TH Ave NE Ste 1
St. Anthony, MN 55421

Mailing address

8401 Golden Valley Rd Ste 330
Golden Valley, MN 55427-4488
Phone (763) 416-7629

Other identifiers 1

IdentifierTypeStateIssuer
298616700MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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 Directory

Locations

18157 Carson Ct NW
Ste C
Elk River, MN 55330
Phone (763) 291-6214

307 Main St NW
Ste B
Elk River, MN 55330
Phone (763) 441-3431

4001 Stinson Blvd NE
Ste 224
Minneapolis, MN 55421
Phone (612) 781-6911

8501 Golden Valley Rd
Ste 210
Minneapolis, MN 55427

2200 Commerce Blvd
Mound, MN 55364
Phone (952) 495-2000

3366 Oakdale Ave N
Ste 402
Robbinsdale, MN 55422

21395 John Milless Dr
Ste 200
Rogers, MN 55374

Practitioners & affiliated clinicians

Practitioners 27

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

View all 27

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": "1255417002",
    "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": "2601 39TH AVE NE STE 1",
            "city": "ST. ANTHONY",
            "state": "MN",
            "postal_code": "55421",
            "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": "298616700",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in St. Anthony, MN

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.

Verify at the official NPI Registry.