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1558350488

NPI Code Detail

MEDICARE: STILLWATER MEDICAL GROUP

MEDICARE: STILLWATER MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician
2	207QS0010X	Sports Medicine (Family Medicine) Physician
3	207R00000X	Internal Medicine Physician
4	207V00000X	Obstetrics & Gynecology Physician
5	207Y00000X	Otolaryngology Physician
6	208000000X	Pediatrics Physician
7	2083X0100X	Occupational Medicine Physician
8	208600000X	Surgery Physician
9	213E00000X	Podiatrist
10	225100000X	Physical Therapist
11	231H00000X	Audiologist
12	363AM0700X	Medical Physician Assistant
13	363L00000X	Nurse Practitioner
14	367A00000X	Advanced Practice Midwife
15	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5439670003	OTHER	MN	MEDICARE NSB

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558350488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STILLWATER MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1500 CURVE CREST BLVD W
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-6040
Country	:	US
Telephone Number	:	651-439-1234
Fax Number	:	651-351-0827

Provider Business Practice Location Address
First Line	:	1500 CURVE CREST BLVD W
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-6040
Country	:	US
Telephone Number	:	651-439-1234
Fax Number	:	651-351-0827

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	MR. KIRK NYBAKKEN
Credential	:
Telephone Number	:	651-275-3302

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	10/18/2011

Similar Medicare Providers

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Practice Location Address:

1500 CURVE CREST BLVD W
STILLWATER, MN
55082-6040

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1417951021 — THOMAS L ZURBRIGGEN MD
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55082-6040

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STILLWATER, MN
55082-6040

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1992799506 — ERIC LEE DUNSMOOR NP
Practice Location Address:

1500 CURVE CREST BLVD W
STILLWATER, MN
55082-6040

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Practice Fax: 651-439-1547

1174513659 — DR. ANDREW EDWARD DORWART MD
Practice Location Address:

1500 CURVE CREST BLVD W
STILLWATER, MN
55082-6040

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1164412649 — DR. MICHAEL RAY BOURNE MD
Practice Location Address:

1500 CURVE CREST BLVD W
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55082-6040

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Directions to “STILLWATER MEDICAL GROUP ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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