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NPI Code Detail

MEDICARE: AUTUMN VASICHEK BMOD

MEDICARE: AUTUMN VASICHEK BMOD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialistND

General Provider Information

NPI Number : 1003658527
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUTUMN VASICHEK BMOD
Provider Business Mailing Address
First Line : 151 S 4TH ST STE 401
Second Line :
City : GRAND FORKS
State : ND
Zip : 58201-4715
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 151 S 4TH ST STE 401
Second Line :
City : GRAND FORKS
State : ND
Zip : 58201-4715
Country : US
Telephone Number : 701-795-3000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2024
Last Update Date : 05/15/2026

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Directions to “ AUTUMN VASICHEK BMOD” Practice Location

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