Provider Demographics
NPI:1245288984
Name:ITASCA SURGICAL CLINIC, PA
Entity type:Organization
Organization Name:ITASCA SURGICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-327-7973
Mailing Address - Street 1:3920 13TH AVE E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3675
Mailing Address - Country:US
Mailing Address - Phone:218-263-7540
Mailing Address - Fax:866-732-0699
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9603
Practice Address - Country:US
Practice Address - Phone:218-327-7973
Practice Address - Fax:218-327-3245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN448327800Medicaid
MN97B18ITOtherBCBS
MNC04216Medicare ID - Type Unspecified
MN020051802Medicare PIN