Provider Demographics
NPI:1205866928
Name:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Entity type:Organization
Organization Name:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:3500 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5335
Mailing Address - Country:US
Mailing Address - Phone:715-817-7520
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-817-7520
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:2006-07-05
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
52D0040190291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1205866928Medicaid
WI1205866928Medicaid
MI424630316Medicaid
MN1205866928Medicaid
WI521329Medicare Oscar/Certification