Basic Information
| Provider Information | |||||||||
| NPI: | 1245288984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ITASCA SURGICAL CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1542 GOLF COURSE RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557449603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183277973 | ||||||||
| FaxNumber: | 2183273245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | MARGO | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2183277973 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 448327800 | 05 | MN | MEDICAID | 97B18IT | 01 | MN | BCBS | OTHER |