1053480103 NPI number — BRENDA LEE CARY MD

Table of content: BRENDA LEE CARY MD (NPI 1053480103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053480103 NPI number — BRENDA LEE CARY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARY
Provider First Name:
BRENDA
Provider Middle Name:
LEE
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:
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:
1053480103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 9TH STREET NORTH
Provider Second Line Business Mailing Address:
ESSENTIA HEALTH VIRGINIA CLINIC
Provider Business Mailing Address City Name:
VIRGINIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-741-0150
Provider Business Mailing Address Fax Number:
715-588-7884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 9TH STREET NORTH
Provider Second Line Business Practice Location Address:
DULUTH CLINIC - VIRGINIA
Provider Business Practice Location Address City Name:
VIRGINIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-741-0150
Provider Business Practice Location Address Fax Number:
715-588-7884
Provider Enumeration Date:
11/06/2006

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: 207Q00000X , with the licence number:  53547 , 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: 34743000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053480103 . This is a "BCBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1053480103 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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