Healthcare Provider Details

I. General information

NPI: 1902446271
Provider Name (Legal Business Name): SUEDEL THERAPEUTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S 31ST ST STE 105
GRAND FORKS ND
58201-3592
US

IV. Provider business mailing address

1311 S WASHINGTON ST
GRAND FORKS ND
58201-5406
US

V. Phone/Fax

Practice location:
  • Phone: 701-317-2897
  • Fax: 701-213-4345
Mailing address:
  • Phone: 701-317-2897
  • Fax: 701-213-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE SUEDEL
Title or Position: AUTHORIZED OFFICIAL
Credential: OT
Phone: 701-317-2897