Healthcare Provider Details

I. General information

NPI: 1588784862
Provider Name (Legal Business Name): SCOTT M WESTERMANN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 W BROADWAY AVE
ROBBINSDALE MN
55422-5604
US

IV. Provider business mailing address

8100 SCOTT AVE N
BROOKLYN PARK MN
55443-2322
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7105
  • Fax: 763-533-0833
Mailing address:
  • Phone: 612-672-7105
  • Fax: 763-533-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1027
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: