1841204286 NPI number — NICOLE L STETHEM MD

Table of content: NICOLE L STETHEM MD (NPI 1841204286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841204286 NPI number — NICOLE L STETHEM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STETHEM
Provider First Name:
NICOLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1841204286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5045
Provider Second Line Business Mailing Address:
PLAZA 2 P.F.S.
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-2000
Provider Business Mailing Address Fax Number:
605-322-2036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 S CLIFF AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-2000
Provider Business Practice Location Address Fax Number:
605-322-2036
Provider Enumeration Date:
07/29/2006

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: 207P00000X , with the licence number:  5671 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0100474 . This is a "BLUE CROSS OF SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 6631210 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46022474331 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0597831 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 254P5ST . This is a "MN BC PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 156124300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5671 . This is a "DAKOTACARE" identifier . This identifiers is of the category "OTHER".




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