1770591927 NPI number — UNDERWOOD CLINIC PC

Table of content: (NPI 1770591927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770591927 NPI number — UNDERWOOD CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNDERWOOD CLINIC 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:
WASHBURN 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:
1770591927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 253
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNDERWOOD
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58576-0253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-442-3148
Provider Business Mailing Address Fax Number:
701-442-3414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNDERWOOD
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-442-3148
Provider Business Practice Location Address Fax Number:
701-442-3414
Provider Enumeration Date:
08/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEIDHOLM
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
701-442-3148

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R25469 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R25051 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 13448 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: A63211044293 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06053002 . This is a "BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 18607 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA6139 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: A63211046001 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 06053001 . This is a "BCBS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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