1811162811 NPI number — FAIRLIGHT MEDICAL CENTER

Table of content: (NPI 1811162811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811162811 NPI number — FAIRLIGHT MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRLIGHT MEDICAL CENTER
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:
WILLISTON RADIOLOGY CONSULTANTS
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:
1811162811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 EAST 4TH STREET
Provider Second Line Business Mailing Address:
PO BOX 1148
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58802-1148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-577-6337
Provider Business Mailing Address Fax Number:
701-577-4867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 4TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58801-5350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-577-6337
Provider Business Practice Location Address Fax Number:
701-577-4867
Provider Enumeration Date:
04/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JASZCZAK
Authorized Official First Name:
LESZEK
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
701-577-6337

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  6414 , 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: 109956169 . This is a "DUNS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 269-961-7243 . This is a "TPIN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 621-111 . This is a "NAICS" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 010182 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0406731 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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