Provider Demographics
NPI:1972524981
Name:FIDELDY, STEVEN NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:NICHOLAS
Last Name:FIDELDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NE 11TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3286
Mailing Address - Country:US
Mailing Address - Phone:218-326-3603
Mailing Address - Fax:218-326-3606
Practice Address - Street 1:118 NE 11TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3286
Practice Address - Country:US
Practice Address - Phone:218-326-3603
Practice Address - Fax:218-326-3606
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62M82ALOtherBCBS PROVIDER NUMBER
MNU93036Medicare UPIN