1225187255 NPI number — MARK P STESIN MD PA

Table of content: (NPI 1225187255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225187255 NPI number — MARK P STESIN MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK P STESIN MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225187255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3366 OAKDALE AVE N
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
ROBBINSDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55422-2948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-520-5876
Provider Business Mailing Address Fax Number:
763-520-1703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3366 OAKDALE AVE N
Provider Second Line Business Practice Location Address:
SUITE 408
Provider Business Practice Location Address City Name:
ROBBINSDALE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55422-2948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-520-5876
Provider Business Practice Location Address Fax Number:
763-520-1703
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STESIN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
763-520-5876

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  1250 , 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: 16877ST . This is a "COMPREHENSIVE CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DD1669 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 203001 . This is a "PREFERRED ONE GROUP CODE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 16877ST . This is a "BLUE CROSS GROUP CODE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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