Healthcare Provider Details

I. General information

NPI: 1528063765
Provider Name (Legal Business Name): STEPHEN M DELISI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RAYMOND AVE STE 130
SAINT PAUL MN
55114-1778
US

IV. Provider business mailing address

700 RAYMOND AVE STE 130
SAINT PAUL MN
55114-1778
US

V. Phone/Fax

Practice location:
  • Phone: 612-699-7778
  • Fax:
Mailing address:
  • Phone: 612-699-7778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number48123
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number46660
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number48123
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: