1396774550 NPI number — MIDLAND PROHEALTH

Table of content: (NPI 1396774550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396774550 NPI number — MIDLAND PROHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDLAND PROHEALTH
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:
COSTCARE MEDICAL STORE
Provider Other Organization Name Type Code:
3
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:
1396774550
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:
3003 32ND AVE S
Provider Second Line Business Mailing Address:
#7
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-6163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-277-1993
Provider Business Mailing Address Fax Number:
701-277-3192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 32ND AVE S
Provider Second Line Business Practice Location Address:
#7
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-277-1993
Provider Business Practice Location Address Fax Number:
701-277-3192
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GEIGER
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
701-277-1993

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9150240 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39354 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 45036 . This is a "COMP CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 45036MI . This is a "CIGNA EMPLOYEE" identifier . This identifiers is of the category "OTHER".
  • Identifier: MHE432581 . This is a "PGA PROCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 45036MI . This is a "BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 45036MI . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5603806 . This is a "MEDICAID" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 56385 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7871 . This is a "BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 76571 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8200344 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 70510 . This is a "BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com