Healthcare Provider Details

I. General information

NPI: 1083698666
Provider Name (Legal Business Name): WILLIAM SCOTT SIEVERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12175 ABERDEEN ST NE
BLAINE MN
55449-4717
US

IV. Provider business mailing address

12175 ABERDEEN ST NE
BLAINE MN
55449-4717
US

V. Phone/Fax

Practice location:
  • Phone: 763-785-4200
  • Fax: 763-785-3314
Mailing address:
  • Phone: 763-785-4200
  • Fax: 763-785-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28818
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: