1831312750 NPI number — RED RIVER FAMILY MEDICINE, PC

Table of content: (NPI 1831312750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831312750 NPI number — RED RIVER FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RED RIVER FAMILY MEDICINE, 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:
1831312750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 MAIN AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-1930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-499-4340
Provider Business Mailing Address Fax Number:
701-499-4341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-499-4340
Provider Business Practice Location Address Fax Number:
701-499-4341
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TWOBEARS
Authorized Official First Name:
SHANTELL
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-499-4340

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  7807 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R28446 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 931G4RE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 98-98110 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 13172 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 14245 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06960/001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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