Healthcare Provider Details

I. General information

NPI: 1144273749
Provider Name (Legal Business Name): ERIC CHARLES ENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 GRAND AVE
DULUTH MN
55807-2742
US

IV. Provider business mailing address

4702 GRAND AVE
DULUTH MN
55807-2742
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-6800
  • Fax: 218-249-6808
Mailing address:
  • Phone: 218-249-6800
  • Fax: 218-249-6808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47407
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: