Healthcare Provider Details

I. General information

NPI: 1871527739
Provider Name (Legal Business Name): RUSSELL SCOTT STICHA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-3734
US

IV. Provider business mailing address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-3734
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax: 320-762-1935
Mailing address:
  • Phone: 320-762-1144
  • Fax: 320-762-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number761
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number761
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: