Basic Information
Provider Information | |||||||||
NPI: | 1386687408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1027 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT LAKES | ||||||||
State: | MN | ||||||||
PostalCode: | 565013409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188475611 | ||||||||
FaxNumber: | 2188470881 | ||||||||
Practice Location | |||||||||
Address1: | 1027 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT LAKES | ||||||||
State: | MN | ||||||||
PostalCode: | 565013409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188475611 | ||||||||
FaxNumber: | 2188470881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 05/31/2012 | ||||||||
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 | 46416 | MN | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 148L7ST | 01 | MN | BLUE SHIELD OF MINNESOTA | OTHER | 15-79505 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER | P00107843 | 01 | MN | RAILROAD MEDICARE | OTHER | 721147300 | 05 | MN |   | MEDICAID | 122731 | 01 | MN | UCARE MINNESOTA | OTHER | 1040121 | 01 | MN | PREFERREDONE | OTHER | HP24872 | 01 | MN | HEALTHPARTNERS | OTHER |