Provider Demographics
NPI:1992787717
Name:SMALLEY, STEPHEN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:SMALLEY
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 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3630
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:651-254-1603
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49050207RC0000X
WI37768-20207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2121079Medicaid
IAI1528Medicare ID - Type Unspecified
IAF99154Medicare UPIN