Healthcare Provider Details

I. General information

NPI: 1861467219
Provider Name (Legal Business Name): HEIDI JEAN KORSTAD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PINE TREE DRIVE
BIGFORK MN
56628
US

IV. Provider business mailing address

135 PINE TREE DRIVE PO BOX 135
BIGFORK MN
56628
US

V. Phone/Fax

Practice location:
  • Phone: 218-743-3232
  • Fax: 218-743-4223
Mailing address:
  • Phone: 218-743-3232
  • Fax: 218-743-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27893
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: