Provider Demographics
NPI:1114982733
Name:SIEWERT, MARK W (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:SIEWERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 1935
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-339-2041
Mailing Address - Fax:612-339-2042
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1935
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-339-2041
Practice Address - Fax:612-339-2042
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40B33SIOtherBC INDIV PROV ID
MN6400642OtherMEDICA INDIV PROV ID
MN6400642OtherMEDICA INDIV PROV ID