Basic Information
| Provider Information | |||||||||
| NPI: | 1538112511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUSHKAT | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | S | ||||||||
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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: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | ESSENTIA HEALTH ST. MARY'S MEDICAL CENTER | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 31075 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 106902 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 56653 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64310758 | 05 | KY | MEDICAID | 1538112511 | 05 | MN | MEDICAID | 1538112511 | 05 | WI | MEDICAID | P00097181 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000328956 | 01 | KY | BLUE CROSS | OTHER | AM7366859 | 01 | KY | DEA | OTHER |