Provider Demographics
NPI:1881862324
Name:MILTON D SODERBERG MD
Entity type:Organization
Organization Name:MILTON D SODERBERG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:D
Authorized Official - Last Name:SODERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-225-3939
Mailing Address - Street 1:1414 W FAIR AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5404
Mailing Address - Country:US
Mailing Address - Phone:906-225-3939
Mailing Address - Fax:906-225-7488
Practice Address - Street 1:1414 W FAIR AVE STE 109
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5404
Practice Address - Country:US
Practice Address - Phone:906-225-3939
Practice Address - Fax:906-225-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMS026190302F00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2025869Medicaid
MI2025869Medicaid
MIA77582Medicare UPIN