Basic Information
| Provider Information | |||||||||
| NPI: | 1851503635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EICHTEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | EDWIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | SSB-6 | ||||||||
| Address2: | 400 E 3RD ST | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 ASH STREET | ||||||||
| Address2: | DULUTH CLINIC-SPOONER | ||||||||
| City: | SPOONER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156352151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49708 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53749-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1851503635 | 01 | MEDICA | OTHER | 392450000 | 05 | MN | MEDICAID | P00436683 | 01 | RRMEDICARE PTAN | OTHER | 16P71EI | 01 | MN | BCBS | OTHER |