Provider Demographics
NPI:1548261969
Name:KOIVUNEN, RAY S (MD)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:S
Last Name:KOIVUNEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1569
Mailing Address - Country:US
Mailing Address - Phone:906-290-5000
Mailing Address - Fax:906-863-2408
Practice Address - Street 1:1110 10TH AVE
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3058
Practice Address - Country:US
Practice Address - Phone:906-290-5000
Practice Address - Fax:906-863-2408
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30118000Medicaid
MI080036031OtherRAILROAD MEDICARE
MI2608388Medicaid
MI080036031OtherRAILROAD MEDICARE
WI30118000Medicaid