Basic Information
Provider Information | |||||||||
NPI: | 1891896239 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COURNEYA | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 366 | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557460366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123005 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Practice Location | |||||||||
Address1: | 1200 E 25TH ST | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557463897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123005 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 07/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MN43125 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0204X | MN43125 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085N0904X | MN43125 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 43125 | MN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 62B06CO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 584142900 | 05 | MN |   | MEDICAID |