Provider Demographics
NPI:1396705018
Name:TREDAL, STEVEN MOORE (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:MOORE
Last Name:TREDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:1661 SAINT ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3733
Practice Address - Country:US
Practice Address - Phone:651-968-5300
Practice Address - Fax:651-646-0205
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26483207P00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
26483Medicare UPIN