MEDICARE: THE DULUTH CLINIC, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician
2	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52D0877366	OTHER	WI	CLIA

General Provider Information

NPI Number	:	1619118759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE DULUTH CLINIC, LTD

Provider Business Mailing Address
First Line	:	1913 BEASER AVE
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-3604
Country	:	US
Telephone Number	:	715-682-4333
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 BEASER AVE
Second Line	:
City	:	ASHLAND
State	:	WI
Zip	:	54806-3604
Country	:	US
Telephone Number	:	715-682-4333
Fax Number	:

Authorized Official
Title or Position	:	EVP
Name	:	MICHAEL C METCALF
Credential	:
Telephone Number	:	218-786-2642

Provider Enumeration Date	:	03/19/2009
Last Update Date	:	04/09/2010

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Directions to “THE DULUTH CLINIC, LTD ” Practice Location

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