Provider Demographics
NPI:1851474506
Name:HEIDE'S MASTECTOMY SERVICES OF DULUTH.
Entity Type:Organization
Organization Name:HEIDE'S MASTECTOMY SERVICES OF DULUTH.
Other - Org Name:HEIDE'S
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WRAZIDLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-722-7860
Mailing Address - Street 1:701 1/2 NORTH 6TH AVE. EAST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1333
Mailing Address - Country:US
Mailing Address - Phone:218-722-7860
Mailing Address - Fax:218-722-7872
Practice Address - Street 1:701 1/2 NORTH 6TH AVE. EAST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1333
Practice Address - Country:US
Practice Address - Phone:218-722-7860
Practice Address - Fax:218-722-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MNN/A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3833743OtherBCBS
WI41166285019OtherBCBS
MN60724OtherHEALTH PARTNERS
MN8211003OtherMEDICA
WI41665200Medicaid
MN1011560OtherPREFERRED ONE
MN784363100Medicaid
MN3833743OtherBCBS