1891721841 NPI number — BRETT K VIBETO MD

Table of content: BRETT K VIBETO MD (NPI 1891721841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891721841 NPI number — BRETT K VIBETO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIBETO
Provider First Name:
BRETT
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1891721841
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 15TH AVE. W.
Provider Second Line Business Mailing Address:
MERCY MEDICAL CENTER
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58801-3821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-774-7400
Provider Business Mailing Address Fax Number:
701-572-1688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 15TH AVE. W.
Provider Second Line Business Practice Location Address:
CRAVEN HAGAN CLINIC
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58801-3821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-572-7651
Provider Business Practice Location Address Fax Number:
701-572-1688
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  48079 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 10618 , 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: 13464 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137084 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DA9021044154 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2366070 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 25809 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 44377 . This is a "LHS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1701454 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 317S5VI . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 440683400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP53212 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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