Provider Demographics
NPI:1801848635
Name:STEIN, GWEN A (MD)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:A
Last Name:STEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1408
Mailing Address - Country:US
Mailing Address - Phone:320-589-7625
Mailing Address - Fax:320-589-7686
Practice Address - Street 1:400 ANNANDALE BLVD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302
Practice Address - Country:US
Practice Address - Phone:651-259-3850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ138872084P0800X
MN377442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
28T44HOOtherBCBS
585241010541OtherPREFERRED ONE
MN358217500Medicaid
8HZ788Medicare ID - Type Unspecified
MN358217500Medicaid