Basic Information
| Provider Information | |||||||||
| NPI: | 1508001629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS KEWEENAW | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASPIRUS KEWEENAW FASTCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 OSCEOLA STREET | ||||||||
| Address2: | |||||||||
| City: | LAURIUM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499132134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063376560 | ||||||||
| FaxNumber: | 9063376562 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | HOUGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064830679 | ||||||||
| FaxNumber: | 9064830686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.