Provider Demographics
NPI:1871842328
Name:SEVENICH, ELLEN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:ANN
Last Name:SEVENICH
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 1:2335 STEWART AVE.
Mailing Address - Street 2:217
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116
Mailing Address - Country:US
Mailing Address - Phone:651-698-4522
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:651-993-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine