Stephen Richard Park

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

25060 Issued in MN

Practice address

1542 Golf Course Rd Ste 204
Grand Rapids, MN 55744-3555

Phone

(218) 999-7000

Fax

(218) 999-7099

NPI assigned

Jul 14, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

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

{
    "created_epoch": "1152835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1525132800000",
    "number": "1447276514",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1542 GOLF COURSE RD STE 204",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557443555",
            "telephone_number": "218-999-7000",
            "fax_number": "218-999-7099"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1542 GOLF COURSE RD STE 204",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557443555",
            "telephone_number": "218-999-7000",
            "fax_number": "218-999-7099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "STEPHEN",
        "middle_name": "RICHARD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-14",
        "last_updated": "2018-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "25060",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "302568300",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Grand Rapids, MN
• Providers in Grand Rapids, MN by specialty
• Family Medicine Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.