Basic Information
| Provider Information | |||||||||
| NPI: | 1306980875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRIDER | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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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 | 2085R0202X | 18518 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 49502 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11786 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00864018 | 01 | MN | RAILROAD MEDICARE | OTHER | 15632 | 05 | ND | MEDICAID |