1912116054 NPI number — PETOSKEY, INC.

Table of content: (NPI 1912116054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912116054 NPI number — PETOSKEY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETOSKEY, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1912116054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 N 2ND AVE W
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55802-1911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-733-6800
Provider Business Mailing Address Fax Number:
218-740-4048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 N 2ND AVE W
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802-1911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-733-6800
Provider Business Practice Location Address Fax Number:
218-740-4048
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KORSCH
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
218-733-6800

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  263020 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: 263020 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 945437000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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