1255505004 NPI number — A FOOT DOCTOR, PLLC

Table of content: (NPI 1255505004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255505004 NPI number — A FOOT DOCTOR, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A FOOT DOCTOR, PLLC
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:
1255505004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2631 12TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-8741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-232-0900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2631 12TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-8741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-232-0900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MORGAN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-232-0900

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  52 , 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: 126502 . This is a "HEALTHPARTNERS HPFIN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 13725 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06796001 . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 03N87MO . This is a "BLUE SHIELD MN GROUP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2700617 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00320486 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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