Provider Demographics
NPI:1619941085
Name:DU RIVAGE, STEPHEN KENT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KENT
Last Name:DU RIVAGE
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 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:6845 LEE AVE N
Practice Address - Street 2:MAIL STOP 31400A
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1717
Practice Address - Country:US
Practice Address - Phone:763-569-0300
Practice Address - Fax:763-569-0311
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29549208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D29353Medicare UPIN