Basic Information
| Provider Information | |||||||||
| NPI: | 1205854080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROISE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 4957 | ND | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 142059 | 01 | ND | UCARE # | OTHER | 14544 | 05 | ND | MEDICAID | 12352 | 01 | ND | SIOUX VALLEY # | OTHER | 88D16RO | 01 | ND | FGO MNBS# | OTHER | HP38337 | 01 | ND | HEALTHPARTNERS # | OTHER | 1100119 | 01 | ND | FGO MEDICA # | OTHER | 17475 | 05 | ND | MEDICAID | 1012767 | 01 | ND | ARAZ # | OTHER | 19107 | 01 | ND | FGO NDBS # | OTHER | DA9011026994 | 01 | ND | PREF 1 # | OTHER | 1100125 | 01 | ND | INN MEDICA # | OTHER | 213627900 | 05 | ND | MEDICAID |