1073601258 NPI number — PRAIRIE ST. JOHN'S CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073601258 NPI number — PRAIRIE ST. JOHN'S CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRAIRIE ST. JOHN'S CLINIC
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:
1073601258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 4TH ST S
Provider Second Line Business Mailing Address:
PO BOX 2027
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-1914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-476-7221
Provider Business Mailing Address Fax Number:
701-476-7261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7616 CURRELL BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-2290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-259-9700
Provider Business Practice Location Address Fax Number:
651-259-9740
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAGNISON
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
701-476-7221

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  5063A , 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: 238T5PR . This is a "MINNESOTA BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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