1023039278 NPI number — COMMUNITY MRI SERVICES, LLC

Table of content: (NPI 1023039278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023039278 NPI number — COMMUNITY MRI SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MRI SERVICES, LLC
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:
1023039278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3223 32ND AVENUE S
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-6278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-297-0305
Provider Business Mailing Address Fax Number:
701-235-9660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1252 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-6316
Provider Business Practice Location Address Fax Number:
218-847-6303
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOFER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-297-0305

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1026467 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 650069200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 269M3CO . This is a "MINNESOTA BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 141965700 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1602881 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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