Basic Information
| Provider Information | |||||||||
| NPI: | 1437132578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REMARK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 WEST ARROWHEAD ROAD | ||||||||
| Address2: | ESSENTIA HEALTH HERMANTOWN CLINIC | ||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 09/22/2016 | ||||||||
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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 | 103T00000X | LP0247 | MN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | CN1041011876 | 01 | PREFERRED ONE | OTHER | 728252400 | 05 | MN | MEDICAID | C009 | 01 | TRICARE WEST | OTHER | 4F712RE | 01 | MN | BCBSMN | OTHER | HP24108 | 01 | HEALTHPARTNERS | OTHER | 01-04927 | 01 | MEDICA | OTHER |