Basic Information
Provider Information | |||||||||
NPI: | 1609811058 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASPIRUS KEWEENAW | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASPIRUS KEWEENAW MEDICAL ARTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 WEST LAKESHORE DRIVE | ||||||||
Address2: |   | ||||||||
City: | HOUGHTON | ||||||||
State: | MI | ||||||||
PostalCode: | 499312200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9064871710 | ||||||||
FaxNumber: | 9064879421 | ||||||||
Practice Location | |||||||||
Address1: | 301 WEST LAKESHORE DRIVE | ||||||||
Address2: |   | ||||||||
City: | HOUGHTON | ||||||||
State: | MI | ||||||||
PostalCode: | 499312200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9064871710 | ||||||||
FaxNumber: | 9064879421 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 05/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PECK | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7158472988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080C160340 | 01 | MI | BLUE CROSS & BLUE SHIELD | OTHER |