Healthcare Provider Details

I. General information

NPI: 1336126317
Provider Name (Legal Business Name): FREDRICK E EKBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E SUPERIOR ST SUITE 109
DULUTH MN
55802-2238
US

IV. Provider business mailing address

925 E SUPERIOR ST SUITE 109
DULUTH MN
55802-2238
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-3700
  • Fax: 218-722-8705
Mailing address:
  • Phone: 218-722-3700
  • Fax: 218-722-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number16940
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number16940
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number16940
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number16940
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16940
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number16940
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number16940
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: