Provider Demographics
NPI:1346206208
Name:BURGESON, STEPHAN G (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:G
Last Name:BURGESON
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 1:777 SELBY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6619
Mailing Address - Country:US
Mailing Address - Phone:651-358-2425
Mailing Address - Fax:651-419-6111
Practice Address - Street 1:777 SELBY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6619
Practice Address - Country:US
Practice Address - Phone:651-358-2425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF20157Medicare UPIN