Healthcare Provider Details

I. General information

NPI: 1255718383
Provider Name (Legal Business Name): LARRY SIEBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E 3RD ST
HIBBING MN
55746-1118
US

IV. Provider business mailing address

126 E 3RD ST
HIBBING MN
55746-1118
US

V. Phone/Fax

Practice location:
  • Phone: 218-966-7024
  • Fax:
Mailing address:
  • Phone: 218-966-7024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberQ757168359619
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: