Provider Demographics
NPI:1972585867
Name:DULUTH GRADUATE MEDICAL EDUCATION COUNCIL INC
Entity Type:Organization
Organization Name:DULUTH GRADUATE MEDICAL EDUCATION COUNCIL INC
Other - Org Name:DULUTH FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD CHAIR
Authorized Official - Prefix:
Authorized Official - First Name:SHAILENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-624-7629
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32674900Medicaid
MN647010600Medicaid
MN69226FAOtherBCBSMN
MN647010600Medicaid