Basic Information
Provider Information | |||||||||
NPI: | 1982694220 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRUGER | ||||||||
FirstName: | KIM | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 10/27/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 40736 | MN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 34530200 | 05 | WI |   | MEDICAID | CN1041024845 | 01 |   | PREFERRED ONE | OTHER | CO26 | 01 |   | TRICARE WEST | OTHER | 01-17519 | 01 |   | MEDICA | OTHER | 445T5KR | 01 | MN | BCBSMN | OTHER | HP30509 | 01 |   | HEALTHPARTNERS | OTHER |