Provider Demographics
NPI:1649296245
Name:NORTHLAND NEUROLOGY AND MYOLOGY PA
Entity type:Organization
Organization Name:NORTHLAND NEUROLOGY AND MYOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCKEE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:218-722-1122
Mailing Address - Street 1:1000 E 1ST ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-722-1122
Mailing Address - Fax:218-722-0600
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:SUITE 202
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-722-1122
Practice Address - Fax:218-722-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN851984Medicaid
WI32852300Medicaid
S1117OtherRAILROAD MEDICARE
WI32852300Medicaid