1154319911 NPI number — MS. GAIL RAE HALVERSON N.P.

Table of content: MS. GAIL RAE HALVERSON N.P. (NPI 1154319911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154319911 NPI number — MS. GAIL RAE HALVERSON N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVERSON
Provider First Name:
GAIL
Provider Middle Name:
RAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1154319911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18408 430TH SWAVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST GRAND FORKS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56721-9257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-739-1820
Provider Business Mailing Address Fax Number:
218-773-1560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 DIVISION AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-775-4251
Provider Business Practice Location Address Fax Number:
701-775-3691
Provider Enumeration Date:
10/06/2005

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: 363LW0102X , with the licence number:  R29615 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LX0001X , with the licence number: R118302-3 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 53595 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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