Basic Information
| Provider Information | |||||||||
| NPI: | 1750710554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRONDAHL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101021290 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 68988 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 17241 | ND | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.