Healthcare Provider Details

I. General information

NPI: 1255945739
Provider Name (Legal Business Name): BLUESTONE PHYSICIAN SERVICES SOUTHEAST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 WATERSIDE DR STE 2525
NORFOLK VA
23510-3316
US

IV. Provider business mailing address

270 MAIN ST N STE 300
STILLWATER MN
55082-6788
US

V. Phone/Fax

Practice location:
  • Phone: 757-777-3433
  • Fax: 855-818-3907
Mailing address:
  • Phone: 651-342-1039
  • Fax: 651-342-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TIM KOEHLER
Title or Position: COO
Credential:
Phone: 651-342-1039