1619941085 NPI number — STEPHEN KENT DU RIVAGE MD

Table of content: STEPHEN KENT DU RIVAGE MD (NPI 1619941085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619941085 NPI number — STEPHEN KENT DU RIVAGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DU RIVAGE
Provider First Name:
STEPHEN
Provider Middle Name:
KENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1619941085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8100 34TH AVE S
Provider Second Line Business Mailing Address:
21110Q
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-883-7961
Provider Business Mailing Address Fax Number:
952-883-5395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6845 LEE AVE N
Provider Second Line Business Practice Location Address:
MAIL STOP 31400A
Provider Business Practice Location Address City Name:
BROOKLYN CENTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-569-0300
Provider Business Practice Location Address Fax Number:
763-569-0311
Provider Enumeration Date:
02/14/2006

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: 208000000X , with the licence number:  29549 , 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)





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