Basic Information
| Provider Information | |||||||||
| NPI: | 1427026780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUNNARSON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH ST. MARY'S MEDICAL CENTER | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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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 | 207P00000X | 40943 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 43477 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 406025300 | 05 | MN | MEDICAID |