1518905512 NPI number — AXIS CLINIC PC

Table of content: (NPI 1518905512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518905512 NPI number — AXIS CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AXIS 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:
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:
1518905512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1451 44TH AVE S STE 120D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-3434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-732-2947
Provider Business Mailing Address Fax Number:
701-732-2945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1451 44TH AVE S STE 120D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-3434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-732-2947
Provider Business Practice Location Address Fax Number:
701-732-4945
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NORMAN
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-792-2947

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  25 , 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: 01042277 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2476885 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 700A8AX . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 115081 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 50900 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26105 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 54900 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 548G3AX . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com