Alicia Gustafson, D.O.

Primary specialty

Sports Medicine (Internal Medicine) PhysicianTaxonomy code 207RS0010X

License

75542 Issued in MN

Practice address

8100 Northland Dr
Bloomington, MN 55431-4800

Phone

(952) 831-8742

NPI assigned

Jun 21, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in TX, MN2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 2

Specialty

Sports Medicine

Education

Edward Via Col of Osteo Medicine-Virginia Campus, 2012

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians

Tria Orthopaedic Center LLCGroup PAC ID 3173570561, 504 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: agustafson1672248@direct.texashealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1780621904
  Medicare reassignment Care Compare group NPD
• Tria Orthopaedic Center LLC

  dba TRIA Orthopaedic Clinic

  • Orthopaedic Surgery Physician
  • Bloomington, MN
  • NPI 1518273085
  Medicare reassignment Care Compare group NPD
• Texas Health Physicians Group

  • Internal Medicine Physician
  • Fort Worth, TX
  • NPI 1174573596

  Family Medicine

  Medicare reassignment NPD
• Park Nicollet Clinic

  • Family Medicine Physician
  • St Louis Park, MN
  • NPI 1063897593
  NPD
• Texas Health Physicians Group

  dba Sleep Healers

  • Sleep Disorder Diagnostic Clinic/Center
  • Fort Worth, TX
  • NPI 1114395969
  NPD
• Texas Health Physicians Group

  dba Sleep Healers

  • Sleep Disorder Diagnostic Clinic/Center
  • Dallas, TX
  • NPI 1174992051
  NPD
• Kootenai Health, Inc.

  • Psychiatry Physician
  • Coeur d'Alene, ID
  • NPI 1174661151
  NPD (past)
• Kootenai Health, Inc.

  dba Kootenai Medical Center Group

  • Emergency Medicine Physician
  • Coeur d'Alene, ID
  • NPI 1235288655
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1340236800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1715299200000",
    "number": "1417210790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8170 33RD AVE S # MS 21110Q",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554254516"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8100 NORTHLAND DR",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554314800",
            "telephone_number": "952-831-8742"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1976 Texan Dr., Suite 106",
            "address_purpose": "LOCATION",
            "city": "Justin",
            "state": "TX",
            "postal_code": "76247",
            "country_code": "US",
            "telephone_number": "682-212-9020",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GUSTAFSON",
        "first_name": "ALICIA",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-06-21",
        "last_updated": "2024-05-10",
        "certification_date": "2024-05-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "S9140",
            "primary": false
        },
        {
            "code": "207QS0010X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sports Medicine",
            "state": "TX",
            "license": "S9140",
            "primary": false
        },
        {
            "code": "207RS0010X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Sports Medicine",
            "state": "MN",
            "license": "75542",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "agustafson1672248@Direct.TexasHealth.org",
            "affiliation": "N",
            "address_1": "1976 Texan Dr., Suite 106",
            "city": "Justin",
            "state": "TX",
            "country_code": "US",
            "postal_code": "76247",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Roberta Rae Gunther, M.A., CCC-SLP
• Gurey LLC (Gurey Health Care Servives)
• Mohamed Abdi Gurre
• Tracey L Guselle, MD
• Melanie Guski
• Mark Charles Gustafson, DC.
• Shane Michael Gustafson, DO
• Hope Katherine Gustason
• Lance Emil Gutfleisch, O.D.
• Abdalaziz Mohamed Hassan Guuled

• Sports Medicine (Internal Medicine) Physician in Bloomington, MN
• Providers in Bloomington, MN by specialty
• Sports Medicine (Internal Medicine) Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.