Healthcare Provider Details

I. General information

NPI: 1578505210
Provider Name (Legal Business Name): EDWARD W CIRIACY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W CONAN ST
ELY MN
55731-1145
US

IV. Provider business mailing address

300 W CONAN ST
ELY MN
55731-1145
US

V. Phone/Fax

Practice location:
  • Phone: 218-365-7900
  • Fax:
Mailing address:
  • Phone: 218-365-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24760
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: