Provider Demographics
NPI:1396755930
Name:BIRDSALL, SCOTT B (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:B
Last Name:BIRDSALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MANKATO AVE
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-4868
Mailing Address - Country:US
Mailing Address - Phone:507-454-3680
Mailing Address - Fax:507-457-4160
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-4868
Practice Address - Country:US
Practice Address - Phone:507-454-3680
Practice Address - Fax:507-457-4160
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30341207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN422283100Medicaid
A37283Medicare UPIN
MN160000199Medicare ID - Type Unspecified