Basic Information
| Provider Information | |||||||||
| NPI: | 1972585867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DULUTH GRADUATE MEDICAL EDUCATION COUNCIL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DULUTH FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 01/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | TREASURER/BOARD OF DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2187231112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32674900 | 05 | WI | MEDICAID | 647010600 | 05 | MN | MEDICAID | 69226FA | 01 | MN | BCBSMN | OTHER |