Basic Information
| Provider Information | |||||||||
| NPI: | 1073546263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADUEGE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 W ARROWHEAD RD | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863540 | ||||||||
| FaxNumber: | 2187228160 | ||||||||
| Practice Location | |||||||||
| Address1: | 4855 W ARROWHEAD RD | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863540 | ||||||||
| FaxNumber: | 2187228160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37217 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 435013800 | 05 | MN | MEDICAID | 435013800 | 05 | WI | MEDICAID |