Healthcare Provider Details

I. General information

NPI: 1972573566
Provider Name (Legal Business Name): KIRK LESLIE SCOFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 ARCADE ST
VADNAIS HEIGHTS MN
55127-7135
US

IV. Provider business mailing address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5770
  • Fax: 651-968-5775
Mailing address:
  • Phone: 651-968-5042
  • Fax: 651-968-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4381
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number54590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: