Basic Information
Provider Information | |||||||||
NPI: | 1669450474 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARMICHAEL | ||||||||
FirstName: | QUINN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 23 W CENTRAL ENTRANCE # 160 | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 558113433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2187223700 | ||||||||
FaxNumber: | 2187228705 | ||||||||
Practice Location | |||||||||
Address1: | 750 E 34TH ST | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557462341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182624881 | ||||||||
FaxNumber: | 2183626699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085P0229X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0203X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 40662 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 40662 | MN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 34067400 | 05 | WI |   | MEDICAID | 258518900 | 05 | MN |   | MEDICAID |