Basic Information
| Provider Information | |||||||||
| NPI: | 1205039856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDCENTER ONE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDCENTER ONE HEALTH SYSTEMS CARRINGTON CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5501 | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585065501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | 7013235709 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 5TH ST N | ||||||||
| Address2: | |||||||||
| City: | CARRINGTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584211223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016527196 | ||||||||
| FaxNumber: | 7013235709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | LEIGH ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7013236000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | ND | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.