Basic Information
Provider Information | |||||||||
NPI: | 1326064817 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREDSTROM | ||||||||
FirstName: | RENE' | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WENTWORTH | ||||||||
OtherFirstName: | RENE' | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2401 DEMERS AVE - ALTRU BUSINESS CENTER | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 58201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017805000 | ||||||||
FaxNumber: | 2185464400 | ||||||||
Practice Location | |||||||||
Address1: | 1200 S COLUMBIA RD - ALTRU HEALTH SYSTEM | ||||||||
Address2: |   | ||||||||
City: | GRAND FORKS | ||||||||
State: | ND | ||||||||
PostalCode: | 58201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017805000 | ||||||||
FaxNumber: | 2185464400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2006 | ||||||||
LastUpdateDate: | 11/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11712 | ND | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 51353 | MN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 11712 | ND | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 010290813 | 05 | VA |   | MEDICAID | 010290864 | 05 | VA |   | MEDICAID | 010290899 | 05 | VA |   | MEDICAID |