Healthcare Provider Details

I. General information

NPI: 1548677974
Provider Name (Legal Business Name): JOSHUA ROBERT ACKERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVENUE NORTH ST CLOUD HOSPITAL
ST CLOUD MN
56303-1901
US

IV. Provider business mailing address

3131 PRINCETON PIKE BUILDING 5 SUITE 109
LAWRENCEVILLE NJ
08648
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-656-7115
Mailing address:
  • Phone: 609-989-9211
  • Fax: 609-896-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number279149
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA09738800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number279149
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number60636
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: