Basic Information
| Provider Information | |||||||||
| NPI: | 1861742918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | STILLWATER MEDICAL GROUP MAHTOMEDI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 CURVE CREST BLVD | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 WILDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551151852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
| FaxNumber: | 6512753325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | BULLARD | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6514391234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.