Provider Demographics
NPI:1083889554
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:DULUTH CLINIC AT FRESENIUS SUPERIOR DIALYSIS UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CAO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-2656
Mailing Address - Street 1:3500 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5335
Mailing Address - Country:US
Mailing Address - Phone:715-395-2199
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-395-2199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-25
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18015Medicare PIN