Provider Demographics
NPI:1437132578
Name:REMARK, PAUL R (LCP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:REMARK
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 WEST ARROWHEAD ROAD
Mailing Address - Street 2:ESSENTIA HEALTH HERMANTOWN CLINIC
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3936
Mailing Address - Country:US
Mailing Address - Phone:218-786-3540
Mailing Address - Fax:
Practice Address - Street 1:330 N 8TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2024
Practice Address - Country:US
Practice Address - Phone:218-723-1112
Practice Address - Fax:218-529-9120
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0247103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN1041011876OtherPREFERRED ONE
MN728252400Medicaid
C009OtherTRICARE WEST
MN4F712REOtherBCBSMN
HP24108OtherHEALTHPARTNERS
01-04927OtherMEDICA
MN689000240Medicare ID - Type Unspecified
680008620Medicare ID - Type UnspecifiedRAILROAD
MN728252400Medicaid