MEDICARE: RED RIVER NEUROLOGY CLINIC

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
1	2084N0400X	Neurology Physician	4231	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255337861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RED RIVER NEUROLOGY CLINIC

Provider Business Mailing Address
First Line	:	2812 17TH AVE S
Second Line	:	STE D
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-780-1401
Fax Number	:	701-780-1404

Provider Business Practice Location Address
First Line	:	2812 17TH AVE S
Second Line	:	STE D
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-780-1401
Fax Number	:	701-780-1404

Authorized Official
Title or Position	:	MANAGER
Name	:	LORAE BENSON
Credential	:
Telephone Number	:	701-780-1401

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	08/22/2020

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