Basic Information
| Provider Information | |||||||||
| NPI: | 1548261969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOIVUNEN | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499301569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062905000 | ||||||||
| FaxNumber: | 9068632408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | MENOMINEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498583058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062905000 | ||||||||
| FaxNumber: | 9068632408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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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 | 207Q00000X | 4301038321 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30118000 | 05 | WI | MEDICAID | 080036031 | 01 | MI | RAILROAD MEDICARE | OTHER | 2608388 | 05 | MI | MEDICAID |