1730106329 NPI number — BRUCE L DOMM MD

Table of content: BRUCE L DOMM MD (NPI 1730106329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730106329 NPI number — BRUCE L DOMM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMM
Provider First Name:
BRUCE
Provider Middle Name:
L
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:
1730106329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58108-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-364-3300
Provider Business Mailing Address Fax Number:
701-364-8906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 9TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASSELTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58012-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-347-4445
Provider Business Practice Location Address Fax Number:
701-347-5276
Provider Enumeration Date:
07/17/2006

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: 207Q00000X , with the licence number:  5341 , 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: 37983 . This is a "SIOUX VALLEY #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 0106110 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 0108127 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 112583400 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142308 . This is a "UCARE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: ND100038 . This is a "LHS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0106108 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 15375 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93416DO . This is a "MNBS 3" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: HP19507 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 336 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: DA9011015505 . This is a "PREFERRED ONE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 00A28DO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 676560 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 93416DO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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