Basic Information
| Provider Information | |||||||||
| NPI: | 1841235140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASP | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396742 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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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 | 207Y00000X | 27793 | MN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 724867900 | 05 | MN | MEDICAID | 410917444 | 01 | MN | SDA-ONE HEALTH PLAN | OTHER | 1008274 | 01 | MN | SDA PREFERRED ONE # | OTHER | HP21423 | 01 | MN | SDA HEALTHPARTNERS # | OTHER | 120252 | 01 | MN | SDA UCARE # | OTHER | 14432 | 05 | ND | MEDICAID | 040013395 | 01 | MN | SDA MEDICARE RR # | OTHER | 10-07748 | 01 | MN | MEDICA-ASP | OTHER | 62D50AS | 01 | MN | SDA BCBS # | OTHER |