1225033715 NPI number — ORTHOPEDIC ASSOCIATES OF DULUTH, P.A.

Table of content: (NPI 1225033715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225033715 NPI number — ORTHOPEDIC ASSOCIATES OF DULUTH, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPEDIC ASSOCIATES OF DULUTH, P.A.
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:
ORTHOPAEDIC ASSOCIATES OF DULUTH, P.A.
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:
1225033715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E 1ST ST
Provider Second Line Business Mailing Address:
STE 404
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-2297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-722-9753
Provider Business Mailing Address Fax Number:
218-722-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E 1ST ST
Provider Second Line Business Practice Location Address:
STE 404
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-2297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-9753
Provider Business Practice Location Address Fax Number:
218-722-6515
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WALLER
Authorized Official First Name:
JUNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
218-625-1886

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  101 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000018080 . This is a "MEDICARE WPS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 78040OR . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: A001 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 177808100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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