Healthcare Provider Details

I. General information

NPI: 1245288984
Provider Name (Legal Business Name): ITASCA SURGICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 GOLF COURSE RD SUITE 202
GRAND RAPIDS MN
55744-9603
US

IV. Provider business mailing address

3920 13TH AVE E SUITE 6
HIBBING MN
55746-3675
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-7973
  • Fax: 218-327-3245
Mailing address:
  • Phone: 218-263-7540
  • Fax: 866-732-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL MARGO
Title or Position: OWNER
Credential: M.D.
Phone: 218-327-7973