1952349169 NPI number — ELISABETH REVOIR MD

Table of content: ELISABETH REVOIR MD (NPI 1952349169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952349169 NPI number — ELISABETH REVOIR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVOIR
Provider First Name:
ELISABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOGENSON
Provider Other First Name:
ELISABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952349169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
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 LL
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:
218-722-5629
Provider Business Mailing Address Fax Number:

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 LL
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:
218-722-5629
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2006

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: 207V00000X , with the licence number:  38650 , 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: 1011800 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 32262000 . This is a "MEDICAID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38T68RE . This is a "BCBSM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: A009 . This is a "TRIWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 847326900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP22609 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 07-00154 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 115834 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 160030895 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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