NPIMap

Organization Active NPI

Northwest Eye Clinic, LLC

  • Ophthalmology Physician
  • Golden Valley, MN
National Provider Identifier
1992044432
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
8501 Golden Valley Rd Ste 100
Golden Valley, MN 55427-4472
Phone
(763) 416-7600
Fax
(763) 416-7634
NPI assigned
Feb 4, 2013
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 SINGLE SPECIALTY GROUP 207W00000X 360 MN Primary

Addresses

Primary practice location

8501 Golden Valley Rd Ste 100
Golden Valley, MN 55427-4472

Mailing address

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

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

Practitioners & affiliated clinicians

Practitioners 5

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": "1359936000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584489600000",
    "number": "1992044432",
    "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": "8501 GOLDEN VALLEY RD STE 100",
            "city": "GOLDEN VALLEY",
            "state": "MN",
            "postal_code": "554274472",
            "telephone_number": "763-416-7600",
            "fax_number": "763-416-7634"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST EYE CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-04",
        "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 SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": "MN",
            "license": "360",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Golden Valley, 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.