Basic Information
Provider Information | |||||||||
NPI: | 1063697928 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RACZ | ||||||||
FirstName: | ROGER | ||||||||
MiddleName: | STEVEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5010 | ||||||||
Address2: |   | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587025010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018575650 | ||||||||
FaxNumber: | 7018575031 | ||||||||
Practice Location | |||||||||
Address1: | 101 3RD AVE SW | ||||||||
Address2: |   | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587013880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018573584 | ||||||||
FaxNumber: | 7018573566 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2008 | ||||||||
LastUpdateDate: | 02/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | DPM.200037 | LA | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0103X | 171 | MT | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 65 | ND | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 01455275 | 05 | MS |   | MEDICAID | 2120743 | 05 | LA |   | MEDICAID |