Provider Demographics
NPI:1518259027
Name:HORN, ELI JACOB (MD)
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:JACOB
Last Name:HORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N 8TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2024
Mailing Address - Country:US
Mailing Address - Phone:218-723-1112
Mailing Address - Fax:218-529-9120
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:2011-05-03
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518259027OtherBCBS
MN1518259027Medicaid
0001-0100617OtherMEDICA
P01111437OtherRR MEDICARE
080023128Medicare PIN