Healthcare Provider Details

I. General information

NPI: 1376760777
Provider Name (Legal Business Name): IVANHOE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 E GEORGE ST
IVANHOE MN
56142-9707
US

IV. Provider business mailing address

366 E GEORGE ST PO BOX 43
IVANHOE MN
56142-9707
US

V. Phone/Fax

Practice location:
  • Phone: 507-694-1100
  • Fax:
Mailing address:
  • Phone: 507-694-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1757969
License Number StateMN

VIII. Authorized Official

Name: DR. TABB MCCLUSKEY
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 507-275-2295