1821186974 NPI number — BETH M HOPPE-STIDHAM PT

Table of content: BETH M HOPPE-STIDHAM PT (NPI 1821186974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821186974 NPI number — BETH M HOPPE-STIDHAM PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOPPE-STIDHAM
Provider First Name:
BETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOPPE
Provider Other First Name:
BETH
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821186974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
SUITE 240N
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-999-6909
Provider Business Mailing Address Fax Number:
651-999-6830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 SHERMAN ST
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-999-6938
Provider Business Practice Location Address Fax Number:
651-702-7343
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4559 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 725514400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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