Healthcare Provider Details

I. General information

NPI: 1396911483
Provider Name (Legal Business Name): SCOTT DANIEL FORDE THIELEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 FELTL RD
MINNETONKA MN
55343-7983
US

IV. Provider business mailing address

5435 FELTL RD
MINNETONKA MN
55343-7983
US

V. Phone/Fax

Practice location:
  • Phone: 952-892-2021
  • Fax:
Mailing address:
  • Phone: 952-892-2021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number19600
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: