Basic Information
| Provider Information | |||||||||
| NPI: | 1730106329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMM | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 9TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CASSELTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580123339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013474445 | ||||||||
| FaxNumber: | 7013475276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5341 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 37983 | 01 | ND | SIOUX VALLEY # | OTHER | 0106110 | 01 | ND | MEDICA # | OTHER | 0108127 | 01 | ND | MEDICA # | OTHER | 112583400 | 05 | ND | MEDICAID | 142308 | 01 | ND | UCARE # | OTHER | ND100038 | 01 | MN | LHS # | OTHER | 0106108 | 01 | ND | MEDICA # | OTHER | 15375 | 05 | ND | MEDICAID | 93416DO | 01 | ND | MNBS 3 | OTHER | HP19507 | 01 | ND | HEALTHPARTNERS # | OTHER | 336 | 01 | ND | NDBS # | OTHER | DA9011015505 | 01 | ND | PREFERRED ONE # | OTHER | 00A28DO | 01 | ND | MNBS # | OTHER | 676560 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | 93416DO | 01 | ND | MNBS # | OTHER |