Basic Information
| Provider Information | |||||||||
| NPI: | 1265541486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICKSTROM | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 9065245126 | ||||||||
| Practice Location | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 9065245126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301086855 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4795539 | 05 | MI | MEDICAID | 080Z710040 CV086855 | 01 | MI | BLUE CROSS - OFFICE | OTHER | 010Z760020 CV086855 | 01 | BLUE CROSS - ER SERVICES | OTHER | 4797112 | 05 | MI | MEDICAID |