Provider Demographics
NPI:1144236688
Name:SODERBERG PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SODERBERG PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SODERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:763-525-9566
Mailing Address - Street 1:3973 ZEALAND AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1160
Mailing Address - Country:US
Mailing Address - Phone:763-525-9566
Mailing Address - Fax:
Practice Address - Street 1:2040 DOUGLAS DR N
Practice Address - Street 2:SUITE 203
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3944
Practice Address - Country:US
Practice Address - Phone:763-525-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18212251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG488OtherMN UCARE
MN6401945OtherMEDICA
MN035J8SOOtherMN BCBS
MN035J8SOOtherMN BCBS