Provider Demographics
NPI:1225046246
Name:BERTHELSEN, STEPHEN OTTO (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:OTTO
Last Name:BERTHELSEN
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8100
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19287207X00000X
MN50213207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G192870Medicaid
A40590Medicare UPIN
CA00G192870Medicare ID - Type Unspecified