1952331159 NPI number — FAMILY MEDICAL CLINIC PC

Table of content: (NPI 1952331159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952331159 NPI number — FAMILY MEDICAL CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CLINIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952331159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 9TH AVE E
Provider Second Line Business Mailing Address:
PO BOX 1049
Provider Business Mailing Address City Name:
LISBON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-683-4711
Provider Business Mailing Address Fax Number:
701-683-3205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 9TH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LISBON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-683-4711
Provider Business Practice Location Address Fax Number:
701-683-3205
Provider Enumeration Date:
07/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHEETS OLSON
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-683-4711

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4909 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1956001 . This is a "NDBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 05171 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13746 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".