1306887393 NPI number — MARYA DAWN WILLIE LRD

Table of content: BARBARA KIREJCZYK MD (NPI 1225142763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306887393 NPI number — MARYA DAWN WILLIE LRD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIE
Provider First Name:
MARYA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LRD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KADOW
Provider Other First Name:
MARYA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LRD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306887393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 EAST THIRD STREET
Provider Second Line Business Mailing Address:
ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55800-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-732-2800
Provider Business Mailing Address Fax Number:
218-732-2857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 PLEASANT AVE S
Provider Second Line Business Practice Location Address:
ESSENTIA HEALTH PARK RAPIDS CLINIC
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56470-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-732-2800
Provider Business Practice Location Address Fax Number:
218-732-2857
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  2280 , 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: 34871 . This is a "LHS/BANNERHEALTH #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6300246 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6300248 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6300247 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP39460 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 23627 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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