MEDICARE: STILLWATER MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	213E00000X	Podiatrist
3	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1861742918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STILLWATER MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1500 CURVE CREST BLVD
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-6040
Country	:	US
Telephone Number	:	651-439-1234
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 WILDWOOD RD
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55115-1852
Country	:	US
Telephone Number	:	651-439-1234
Fax Number	:	651-275-3325

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	MR. ROSS BULLARD
Credential	:
Telephone Number	:	651-439-1234

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	07/29/2013

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