Provider Demographics
NPI:1730129503
Name:STILLMAN, M. THOMAS (MD)
Entity type:Individual
Prefix:
First Name:M. THOMAS
Middle Name:
Last Name:STILLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-8723
Mailing Address - Fax:612-904-4263
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:R7
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-2300
Practice Address - Fax:612-904-4358
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16985207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN945887500Medicaid
MN945887500Medicaid
MN660000005Medicare ID - Type Unspecified