Provider Demographics
| NPI: | 1558350488 |
|---|---|
| Name: | STILLWATER MEDICAL GROUP |
| Entity Type: | Organization |
| Organization Name: | STILLWATER MEDICAL GROUP |
| Other - Org Name: | STILLWATER MEDICAL GROUP, PA |
| Other - Org Type: | Former Legal Business Name |
| Authorized Official - Title/Position: | DIRECTOR OF FINANCE |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | KIRK |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | NYBAKKEN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 651-275-3302 |
| Mailing Address - Street 1: | 1500 CURVE CREST BLVD W |
| Mailing Address - Street 2: | |
| Mailing Address - City: | STILLWATER |
| Mailing Address - State: | MN |
| Mailing Address - Zip Code: | 55082-6040 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 651-439-1234 |
| Mailing Address - Fax: | 651-351-0827 |
| Practice Address - Street 1: | 1500 CURVE CREST BLVD W |
| Practice Address - Street 2: | |
| Practice Address - City: | STILLWATER |
| Practice Address - State: | MN |
| Practice Address - Zip Code: | 55082-6040 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 651-439-1234 |
| Practice Address - Fax: | 651-351-0827 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-10-13 |
| Last Update Date: | 2011-10-18 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2083X0100X | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MN | 5439670003 | Other | MEDICARE NSB |
| WI | 32882900 | Medicaid | |
| MN | 802128700 | Medicaid | |
| WI | 32834400 | Medicaid | |
| WI | 32834400 | Medicaid | |
| MN | C03865 | Medicare PIN | |
| MN | 802128700 | Medicaid |
