Provider Demographics
NPI:1194756601
Name:STAAHL, GUSTAV E (MD)
Entity type:Individual
Prefix:
First Name:GUSTAV
Middle Name:E
Last Name:STAAHL
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:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4003207L00000X
MN26153207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2000709OtherMEDICA #
NDDA9011015591OtherPREFERRED ONE #
ND19418STOtherMNBS #
ND2000710OtherMEDICA #
ND676652OtherAMERICA'S PPO/ARAZ #
ND860790700Medicaid
MN4F458STOtherMNBS #
NDHP38335OtherHEALTHPARTNERS #
ND1619OtherNDBS #
ND3535OtherSIOUX VALLEY #
ND12404Medicaid
NDND200063OtherLHS #
ND142067OtherUCARE #
NDDA9011015591OtherPREFERRED ONE #
ND142067OtherUCARE #
ND676652OtherAMERICA'S PPO/ARAZ #
ND1619OtherNDBS #