Provider Demographics
NPI:1083698666
Name:SIEVERT, WILLIAM SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SCOTT
Last Name:SIEVERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12175 ABERDEEN ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4717
Mailing Address - Country:US
Mailing Address - Phone:763-785-4200
Mailing Address - Fax:763-785-3314
Practice Address - Street 1:12175 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4717
Practice Address - Country:US
Practice Address - Phone:763-785-4200
Practice Address - Fax:763-785-3314
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93978Medicare UPIN