Provider Demographics
NPI:1821251455
Name:OCCUPATIONAL AND MANUAL MEDICINE OF DULUTH
Entity Type:Organization
Organization Name:OCCUPATIONAL AND MANUAL MEDICINE OF DULUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:OBST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-724-6002
Mailing Address - Street 1:1420 LONDON RD
Mailing Address - Street 2:SUITE 102B
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2433
Mailing Address - Country:US
Mailing Address - Phone:218-724-6002
Mailing Address - Fax:
Practice Address - Street 1:1420 LONDON RD
Practice Address - Street 2:SUITE 102B
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2433
Practice Address - Country:US
Practice Address - Phone:218-724-6002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304282083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN264783400Medicaid
MN264783400Medicaid