1639159338 NPI number — MRS. MARY LYNN BERNTSON OTRL CHT

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639159338 NPI number — MRS. MARY LYNN BERNTSON OTRL CHT

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BERNTSON

Provider First Name:

MARY

Provider Middle Name:

LYNN

Provider Name Prefix Text:

MRS.

Provider Name Suffix Text:

Provider Credential Text:

OTRL CHT

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

FLORENCE

Provider Other First Name:

MARY

Provider Other Middle Name:

LYNN

Provider Other Name Prefix Text:

MISS

Provider Other Name Suffix Text:

Provider Other Credential Text:

OTRL

Provider Other Last Name Type Code:

1

NPI Number:

1639159338

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/01/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 5074

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SIOUX FALLS

Provider Business Mailing Address State Name:

SD

Provider Business Mailing Address Postal Code:

57117-5074

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

701-732-2947

Provider Business Mailing Address Fax Number:

701-732-2945

Provider First Line Business Practice Location Address:

3035 DEMERS AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

GRAND FORKS

Provider Business Practice Location Address State Name:

ND

Provider Business Practice Location Address Postal Code:

58201-4040

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

701-746-7521

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

01/19/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 225X00000X , with the licence number:  100966 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 225X00000X , with the licence number: AA522599 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 225X00000X , with the licence number: 25 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 24561 . This is a "NORIDIAN MUTUAL" identifier . This identifiers is of the category "OTHER".
• Identifier: 341M0BE . This is a "BC/BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 24561 . This is a "BCBS ND" identifier . This identifiers is of the category "OTHER".
• Identifier: HP62219 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
• Identifier: 2605838 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 64-05705 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
• Identifier: 24780 . This is a "DEMERS LOCATION" identifier . This identifiers is of the category "OTHER".
• Identifier: 54901 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 201942600 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 1042277 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".