Individual
CRAIG A VICKSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D
Contact information
Practice address
3605 MAYFAIR AVE, HIBBING, MN 55746-2935
(218) 262-3441
(906) 524-5126
Mailing address
3605 MAYFAIR AVE, HIBBING, MN 55746-2935
(218) 262-3441
(906) 524-5126
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4301086855
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
010Z760020 CV086855
BLUE CROSS - ER SERVICES
—
01
—
080Z710040 CV086855
BLUE CROSS - OFFICE
MI
05
—
4795539
—
MI
05
—
4797112
—
MI
Enumeration date
08/30/2006
Last updated
09/13/2013
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