Provider Demographics
NPI:1710104658
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:DULUTH CLINIC AT LAKEVIEW MEDICAL CENTER SPOONER DIALYSIS UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:METCALF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-2642
Mailing Address - Street 1:819 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1201
Mailing Address - Country:US
Mailing Address - Phone:715-635-5303
Mailing Address - Fax:
Practice Address - Street 1:819 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1201
Practice Address - Country:US
Practice Address - Phone:715-635-5303
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:2007-04-20
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
WI52D0040177OtherCLIA
WI000004010Medicare PIN