Basic Information
| Provider Information | |||||||||
| NPI: | 1700125150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DICKINSON COUNTY HEALTHCARE SYSTEM | ||||||||
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| OtherOrganizationName: | DICKINSON HEALTH PARTNERS - INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765670 | ||||||||
| FaxNumber: | 9062280215 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 S STEPHENSON AVE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765970 | ||||||||
| FaxNumber: | 9062280215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 06/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | DUBORD | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9067765759 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.