ALICIA GUSTAFSON (D.O.) – Sports Medicine (Internal Medicine) Physician, NPI 1417210790
Sports Medicine (Internal Medicine) Physician
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Profile Insights
NPPES metrics only — not quality of care.
496 SPORTS MEDICINE in TX
Provider Addresses for ALICIA GUSTAFSON (D.O.)
1976 Texan Dr., Suite 106
Justin, TX 76247
Phone: (682) 212-9020
Type: Location
2003 KOOTENAI HEALTH WAY
COEUR D ALENE, ID 838146051
Phone: (208) 625-3640
Fax: (208) 625-3645
Type: Mailing
700 W IRONWOOD DR STE 120
COEUR D ALENE, ID 838144405
Phone: (208) 625-3640
Fax: (208) 625-3645
Type: Location
8170 33RD AVE S # MS 21110Q
BLOOMINGTON, MN 554254516
Phone:
Type: Mailing
8100 NORTHLAND DR
BLOOMINGTON, MN 554314800
Phone: (952) 831-8742
Type: Location
1976 TEXAN DR., SUITE 106
JUSTIN, TX 76247
Phone: (682) 212-9020
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
CMS reports 1 Open Payments records for all available years, with a total value of $18.
Total Amount is formed as General ($18) + Research ($0) + Ownership ($0) = $18.
Last reported payment date: 2023-04-06 • Largest payer in this snapshot: Exact Sciences Corporation ($18).
Total Amount
$18
General + Research + Ownership
Payments
1
Total payment records
General Amount
$18
General payments
Research Amount
$0
Research funding
Ownership Amount
$0
Ownership interests
Ownership Count
0
Ownership records
Last Payment Date
2023-04-06
Latest reported date
Top Companies
Largest payers in this snapshot
| Company | Amount |
|---|---|
| Exact Sciences Corporation | $18 |
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2024-06-18
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking 2 Medicare enrollment records; no due dates published yet.
Enrollment records
2
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20210104002157 | I | Family Practice | TX | TBD |
| I20240618001882 | I | Sports Medicine | MN | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
Top Medicare procedures (2023) · refreshed 2026-05-27
| HCPCS | Description | Services | Beneficiaries | Medicare allowed |
|---|---|---|---|---|
| 99214 | Established patient office or other outpatient visit, 30-39 minutes | 75 | 39 | $0 |
| 99213 | Established patient office or other outpatient visit, 20-29 minutes | 50 | 31 | $0 |
| 99204 | New patient office or other outpatient visit, 45-59 minutes | 16 | 16 | $0 |
| 99203 | New patient office or other outpatient visit, 30-44 minutes | 15 | 15 | $0 |
| G0439 | Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit | 15 | 15 | $0 |
Insurance plans in this area (ZIP 76247)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| O B S T E T R I C S/ G Y N E C O L O G Y | MN | |
| Family Practice | MN | |
| - | MN | |
| Pulmonary Disease, Critical Care (Intensivists), Internal Medicine | MN | |
| Cardiac Electrophysiology | MN | |
| Family Practice | MN | |
| Physician Assistant | MN | |
| Physical Therapist In Private Practice | MN | |
| Physician Assistant | MN | |
| D E R M A T O L O G Y | MN |
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