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General NPI Number Information
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NPI Number | 1255945739
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Entity Type | Organization
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Legal Business Name | BLUESTONE PHYSICIAN SERVICES SOUTHEAST LLC
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Dates
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Enumeration Date | 09/02/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 999 WATERSIDE DR STE 2525
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City | NORFOLK
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State | VA
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Zip | 23510-3316
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Country | US
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Telephone | 757-777-3433
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Fax | 855-818-3907
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Provider Business Mailing Address
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Address Line | 270 MAIN ST N STE 300
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City | STILLWATER
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State | MN
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Zip | 55082-6788
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Country | US
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Telephone | 651-342-1039
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Fax | 651-342-1428
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Authorized Official
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Title or Position | COO
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Name | TIM KOEHLER
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Credential |
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Telephone | 651-342-1039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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