Basic Information
| Provider Information | |||||||||
| NPI: | 1881798585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KATHLEEN SULENTICH MD FACOG LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 1ST ST S | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187416221 | ||||||||
| FaxNumber: | 2187412550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SULENTICH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2187416221 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 85263SU | 01 | MN | BCBS | OTHER |