Provider Demographics
NPI:1386644730
Name:VANDERSTOEP, PHILIP H (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:H
Last Name:VANDERSTOEP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-257-5595
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:320-257-5595
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN225882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104072300Medicaid
MN300039116OtherRAILROAD MEDICARE
MN106088C561OtherUCARE OF MINNESOTA
MN26650OtherARAZ/ AMERICA'S PPO
MN16-29701OtherMEDICA
MN965251008761OtherPREFERRED ONE
MN54886VAOtherBLUE CROSS BLUE SHIELD
MNHP25529OtherHEALTH PARTNERS
MN411772562OtherGREATWEST HEALTHCARE
MN309000579Medicare ID - Type Unspecified
MN965251008761OtherPREFERRED ONE