1649320524 NPI number — ASPIRUS KEWEENAW

Table of content: (NPI 1649320524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649320524 NPI number — ASPIRUS KEWEENAW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASPIRUS KEWEENAW
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASPIRUS KEWEENAW LAKE LINDEN CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649320524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 OSCEOLA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAURIUM
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49913-2134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-337-6560
Provider Business Mailing Address Fax Number:
906-337-6562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 CALUMET STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE LINDEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49945-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-296-5040
Provider Business Practice Location Address Fax Number:
906-296-1006
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PECK
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
VP REVENUE CYCLE
Authorized Official Telephone Number:
715-847-2988

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00108 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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