Healthcare Provider Details

I. General information

NPI: 1407235088
Provider Name (Legal Business Name): EMILY MARIE HVIDSTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY MARIE LENZ

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E 1ST ST
DULUTH MN
55805-1901
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR-10262
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-45077
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number67847
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: