Basic Information
| Provider Information | |||||||||
| NPI: | 1336170265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOLLOM | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | G | ||||||||
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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: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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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 | 208100000X | 5279 | ND | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 681203100 | 05 | ND | MEDICAID | 126895 | 01 | ND | UCARE # | OTHER | 911595 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | HP25769 | 01 | ND | HEALTHPARTNERS # | OTHER | ND200062 | 01 | ND | LHS # | OTHER | 2300159 | 01 | ND | MEDICA # | OTHER | 15146 | 05 | ND | MEDICAID | 2300113 | 01 | ND | MEDICA # | OTHER | DA9011015590 | 01 | ND | PREFERRED ONE # | OTHER | 16583SO | 01 | ND | MNBS # | OTHER | 2222 | 01 | ND | NDBS # | OTHER | AS2097079 | 01 | ND | DEA # | OTHER |