1235488438 NPI number — SMDC MEDICAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235488438 NPI number — SMDC MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMDC MEDICAL CENTER
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:
ESSENTIA HEALTH DULUTH-AMBERWING 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:
1235488438
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 PECAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-355-2100
Provider Business Mailing Address Fax Number:
218-355-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 PECAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-355-2100
Provider Business Practice Location Address Fax Number:
218-355-2105
Provider Enumeration Date:
09/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOREN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
218-786-1009

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1033153895 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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