Basic Information
| Provider Information | |||||||||
| NPI: | 1285601542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2182623025 | ||||||||
| Practice Location | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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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 | 208600000X | 53670 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020013501 | 01 | IA | RRMC | OTHER | P00424578 | 01 | IA | RR MED | OTHER | 70238 | 01 | IA | BLUE SHIELD | OTHER | 1285601542 | 05 | IA | MEDICAID | 1012039 | 05 | IA | MEDICAID |