Basic Information
| Provider Information | |||||||||
| NPI: | 1649320524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASPIRUS KEWEENAW | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ASPIRUS KEWEENAW LAKE LINDEN CLINIC | ||||||||
| 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: | 110 CALUMET STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE LINDEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499451308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062965040 | ||||||||
| FaxNumber: | 9062961006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7158472988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00108 | 01 | MI | BLUE CROSS | OTHER |