Provider Demographics
NPI:1841204286
Name:STETHEM, NICOLE L (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:STETHEM
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:PO BOX 5045
Mailing Address - Street 2:PLAZA 2 P.F.S.
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-2000
Mailing Address - Fax:605-322-2036
Practice Address - Street 1:1325 S CLIFF AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1007
Practice Address - Country:US
Practice Address - Phone:605-322-2000
Practice Address - Fax:605-322-2036
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5671207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0100474OtherBLUE CROSS OF SD
SD6631210Medicaid
NE46022474331Medicaid
IA0597831Medicaid
MN254P5STOtherMN BC PROVIDER #
MN156124300Medicaid
5671OtherDAKOTACARE
MN156124300Medicaid
SDS100474Medicare PIN
SD6631210Medicaid