Basic Information
Provider Information | |||||||||
NPI: | 1629113477 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDCENTER ONE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDCENTER ONE HEALTH SYSTEMS FAMILY MEDICAL CENTER NORTH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5501 | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585065501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013236000 | ||||||||
FaxNumber: | 7013235709 | ||||||||
Practice Location | |||||||||
Address1: | 2830 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585031482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013236400 | ||||||||
FaxNumber: | 7013235709 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | LEIGH ANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7013236000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | ND | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.