Healthcare Provider Details

I. General information

NPI: 1427057447
Provider Name (Legal Business Name): ANDREW WILLIAM MCKIBBEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FAIRVIEW RANGE MEDICAL CENTER 750 E 34TH ST
HIBBING MN
55746-2341
US

IV. Provider business mailing address

FAIRVIEW RANGE MEDICAL CENTER 750 E 34TH ST
HIBBING MN
55746-2341
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-2258
  • Fax: 612-672-6041
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36629
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36629
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36629
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: