Provider Demographics
NPI:1780690735
Name:HALLSTROM, STEVEN W (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:W
Last Name:HALLSTROM
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 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:2601 CENTENNIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3087
Practice Address - Country:US
Practice Address - Phone:651-777-7414
Practice Address - Fax:651-748-5839
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN779302200Medicaid
MN779302200Medicaid