Healthcare Provider Details

I. General information

NPI: 1861742918
Provider Name (Legal Business Name): STILLWATER MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WILDWOOD RD
SAINT PAUL MN
55115-1852
US

IV. Provider business mailing address

1500 CURVE CREST BLVD
STILLWATER MN
55082-6040
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-1234
  • Fax: 651-275-3325
Mailing address:
  • Phone: 651-439-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. ROSS BULLARD
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 651-439-1234