Basic Information
| Provider Information | |||||||||
| NPI: | 1376065987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EAST THIRD STREET | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187861183 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 EAST SECOND STREET | ||||||||
| Address2: | ESSENTIA HEALTH POLINSKY MEDICAL REHABILITATION | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187865360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2017 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PENDING | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.