Basic Information
| Provider Information | |||||||||
| NPI: | 1407851413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALTON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 W ICE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499359526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062656121 | ||||||||
| FaxNumber: | 9062654245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 W ICE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499358507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062658189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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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 | 208000000X | 4301071649 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 4301071649 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | RD071649 | 01 | MI | BCBS OF MI | OTHER | 34010000 | 01 | WI | EDS | OTHER | 3461280 | 05 | MI | MEDICAID | 700C61000 | 01 | BCBS, MEDICARE PLUS BLUE | OTHER |