Provider Demographics
NPI:1104927169
Name:SODERBERG, ELDON (PT)
Entity type:Individual
Prefix:
First Name:ELDON
Middle Name:
Last Name:SODERBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 DOUGLAS DR N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3944
Mailing Address - Country:US
Mailing Address - Phone:763-925-9566
Mailing Address - Fax:763-544-2180
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:763-925-9566
Practice Address - Fax:763-544-2180
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18212251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN035J9SOOtherMN BCBS
MN370085200Medicaid
MN123593400OtherUS DEPT OF LABOR
MN173205Medicaid
MN6401945OtherMEDICA
MN650000665Medicare ID - Type UnspecifiedMN MEDICARE