Healthcare Provider Details

I. General information

NPI: 1518915511
Provider Name (Legal Business Name): MARK TSIBULSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LABREE AVE S
THIEF RIVER FALLS MN
56701
US

IV. Provider business mailing address

120 LABREE AVE S NORTHWEST MEDICAL CENTER MENTAL HEALTH DIVISION
THIEF RIVER FALLS MN
56701
US

V. Phone/Fax

Practice location:
  • Phone: 218-683-4351
  • Fax: 218-683-4362
Mailing address:
  • Phone: 218-683-4351
  • Fax: 218-683-4362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number42279
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: