Basic Information
| Provider Information | |||||||||
| NPI: | 1851388961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAKOTA SPECIALTY INSTITUTE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INNOVIS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648051 | ||||||||
| FaxNumber: | 7013648479 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648051 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALKAN | ||||||||
| AuthorizedOfficialFirstName: | PETRICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP PRACTICE MANAGEMENT/MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 7013646202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 5067A | ND | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1B02HIN | 01 | MN | MINNESOTA BLUECROSS BLUES | OTHER | 01440 | 05 | ND | MEDICAID | 058G0IN | 01 | MN | MINNESOTA BLUE CROSS BLUE | OTHER | 12195 | 01 | ND | BLUECROSS BLUESHIELD OF N | OTHER | 948155900 | 05 | ND | MEDICAID |