Healthcare Provider Details

I. General information

NPI: 1881953461
Provider Name (Legal Business Name): RONALD CARL SKOOGBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 HARBOR LANE SUITE 101
PLYMOUTH MN
55447-5141
US

IV. Provider business mailing address

3025 HARBOR LANE SUITE 101
PLYMOUTH MN
55447-5141
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-3737
  • Fax: 866-602-2777
Mailing address:
  • Phone: 763-746-3737
  • Fax: 866-602-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: