1467571745 NPI number — RED RIVER SPINE ASSOCIATES, PC

Table of content: (NPI 1467571745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467571745 NPI number — RED RIVER SPINE ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER SPINE ASSOCIATES, 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:
1467571745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2829 UNIVERSITY DR 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:
58103-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-280-0057
Provider Business Mailing Address Fax Number:
701-365-0086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2829 UNIVERSITY DR S
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-280-0057
Provider Business Practice Location Address Fax Number:
701-365-0086
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
701-280-0057

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  5781 , 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: 17106 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59680200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4474 . This is a "ND BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: CS9503 . This is a "RR MEDICARE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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