Basic Information
Provider Information | |||||||||
NPI: | 1255493565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SETTERBERG | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | ROGER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12915 63RD AVE N | ||||||||
Address2: |   | ||||||||
City: | MAPLE GROVE | ||||||||
State: | MN | ||||||||
PostalCode: | 553696001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7633835800 | ||||||||
FaxNumber: | 7633835801 | ||||||||
Practice Location | |||||||||
Address1: | 6545 FRANCE AVE S | ||||||||
Address2: | SUITE 302 | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9522309100 | ||||||||
FaxNumber: | 9525441500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2006 | ||||||||
LastUpdateDate: | 02/06/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 36051 | MN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 36051 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 152T45E | 01 | ND | BCBC | OTHER | 18653 | 05 | ND |   | MEDICAID | 539860600 | 05 | MN |   | MEDICAID |