Basic Information
| Provider Information | |||||||||
| NPI: | 1033173414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOEHLER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550573081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076639000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43309 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 43309 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 482493800 | 05 | MN | MEDICAID |