1548261969 NPI number — RAY S KOIVUNEN MD

Table of content: RAY S KOIVUNEN MD (NPI 1548261969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548261969 NPI number — RAY S KOIVUNEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOIVUNEN
Provider First Name:
RAY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548261969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 CAMPUS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANCOCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49930-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-290-5000
Provider Business Mailing Address Fax Number:
906-863-2408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENOMINEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49858-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-290-5000
Provider Business Practice Location Address Fax Number:
906-863-2408
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301038321 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30118000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080036031 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2608388 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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