MEDICARE: BELLIN HEALTH IRON MOUNTAIN INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1972092831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLIN HEALTH IRON MOUNTAIN INC

Provider Business Mailing Address
First Line	:	PO BOX 22487
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54305-2487
Country	:	US
Telephone Number	:	920-445-7226
Fax Number	:	920-445-7229

Provider Business Practice Location Address
First Line	:	2001 MINNEAPOLIS AVE STE D
Second Line	:
City	:	GLADSTONE
State	:	MI
Zip	:	49837-2060
Country	:	US
Telephone Number	:	906-776-5640
Fax Number	:	906-776-5639

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	DENISE K STROOBANTS
Credential	:
Telephone Number	:	920-445-7226

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	05/07/2018

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