Northwest Eye Clinic, LLC

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

Last updated

Mar 18, 2020By 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

Kelly Pettengill

Title

Credentialing and Data Management

Phone

(763) 416-7629

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Other NPIs on the same Medicare enrollment 7

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Maple Grove, MN
  • NPI 1164508917

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Minnetonka, MN
  • NPI 1437235280

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1497837306

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Wayzata, MN
  • NPI 1528144375

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Wayzata, MN
  • NPI 1891871646

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1992044432

  O20040204000843

  Same enrollment
• Northwest Eye Clinic, P.a.

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1346326196

  O20040204000843

  Same enrollment

Locations

Practitioners 27

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.

• John S Berestka, MD

  • Ophthalmology Physician
  • Wayzata, MN
  • NPI 1114905072
  NPD
• Alejandra Decanini Mancera, M.D.

  • Ophthalmology Physician
  • Maple Grove, MN
  • NPI 1174799357
  NPD
• Jesse Dovich, M.D.

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1821188996
  NPD
• Timothy J Ehlen, MD

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1184602047
  NPD
• Emily Ellingson, O.D.

  • Optometrist
  • Golden Valley, MN
  • NPI 1356835748
  NPD
• Marni G Feldmann, MD

  • Retina Specialist (Ophthalmology) Physician
  • Golden Valley, MN
  • NPI 1730138595
  NPD
• Kari Fossum, MD

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1215556212
  NPD
• Richard S Freeman, MD

  • Ophthalmology Physician
  • Minnetonka, MN
  • NPI 1356329189
  NPD
• Tanya Glaser, M.D.

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1164840211
  NPD
• Brian J Hamann, OD

  • Optometrist
  • Maple Grove, MN
  • NPI 1700864667
  NPD
• Mila Jacoba Heersink Dovich, MD

  • Ophthalmology Physician
  • Golden Valley, MN
  • NPI 1679707665
  NPD
• Christopher Kruthoff, OD

  • Optometrist
  • Wayzata, MN
  • NPI 1326425364
  NPD

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": [],
    "endpoints": [],
    "other_names": []
}

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• Ophthalmology Physician in St Anthony, MN
• Providers in St Anthony, MN by specialty
• Ophthalmology Physician in Minnesota

• 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.