Basic Information
Provider Information | |||||||||
NPI: | 1770516890 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAITER CLINIC, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 417 SKYLINE BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 557201198 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791271 | ||||||||
FaxNumber: | 2188799617 | ||||||||
Practice Location | |||||||||
Address1: | 417 SKYLINE BOULEVARD | ||||||||
Address2: |   | ||||||||
City: | CLOQUET | ||||||||
State: | MN | ||||||||
PostalCode: | 557201198 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2188791271 | ||||||||
FaxNumber: | 2188799617 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 11/13/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TURONIE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | JEROME | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2188791271 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 6177184 | MN | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 127308600 | 05 | MN |   | MEDICAID | 78201RA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |