Basic Information
| Provider Information | |||||||||
| NPI: | 1083956056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARYNIK | ||||||||
| FirstName: | ASHLEE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SCALCUCCI | ||||||||
| OtherFirstName: | ASHLEE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH ST. MARY'S MEDICAL CENTER | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH DULUTH CLINIC | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12279-24 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 8977 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1083956056 | 05 | WI | MEDICAID |