Provider Demographics
NPI:1790775393
Name:SEVERNAK, TODD M (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:SEVERNAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46624207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP36739OtherHEALTH PARTNERS
P00138776OtherRR MEDICARE
1032146OtherPREFERRED ONE
71204OtherFIRST HEALTH PLAN
130621OtherUCARE
312M8SEOtherBLUE CROSS BLUE SHIELD
2121657OtherARAZ GROUP AMERICAS PPO
706112900OtherMEDICAL ASSISTANCE MA
92204OtherONE HEALTH PLAN GREAT WES
0406641OtherMEDICA HEALTH PLANS
MN706112900Medicaid
MN110009583Medicare PIN
71204OtherFIRST HEALTH PLAN