Healthcare Provider Details

I. General information

NPI: 1710905351
Provider Name (Legal Business Name): STEPHEN R HIETALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 3RD ST SW
PERHAM MN
56573-1108
US

IV. Provider business mailing address

665 3RD ST SW
PERHAM MN
56573-1108
US

V. Phone/Fax

Practice location:
  • Phone: 218-347-1200
  • Fax: 218-346-4043
Mailing address:
  • Phone: 218-347-1200
  • Fax: 218-346-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28147
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: