Basic Information
| Provider Information | |||||||||
| NPI: | 1669419610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUKUP | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19052 INMAN TRL | ||||||||
| Address2: | |||||||||
| City: | LAKEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550444701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524696925 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 W 140TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528083052 | ||||||||
| FaxNumber: | 9528462202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7269 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 210K0SO | 01 | MN | BLUECROSS BLUESHEILD | OTHER | 011698000 | 05 | MN | MEDICAID | 6404216 | 01 | MN | MEDICA | OTHER | HP39430 | 01 | MN | HEALTHPARTNERS | OTHER |