Provider Demographics
NPI:1679541965
Name:FISKER, STEVEN G (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:G
Last Name:FISKER
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 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:415 BARCLAY AVE
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-5139
Practice Address - Country:US
Practice Address - Phone:218-587-4416
Practice Address - Fax:218-587-2677
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN470705200Medicaid
MNE21781Medicare UPIN