1750326070 NPI number — FERGUS FALLS MEDICAL GROUP, P.A.

Table of content: (NPI 1750326070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750326070 NPI number — FERGUS FALLS MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FERGUS FALLS MEDICAL GROUP, P.A.
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:
BROWN'S VALLEY CLINIC
Provider Other Organization Name Type Code:
5
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:
1750326070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 S MILL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUS FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56537-2756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-739-2221
Provider Business Mailing Address Fax Number:
218-739-5501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 WEST BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWN'S VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-695-8526
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILKUS
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
218-739-2221

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  44 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00-01587 . This is a "BVC MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 10344 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 62345FE . This is a "BVC BCBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 109516 . This is a "BVC UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".