MEDICARE: RETINA CONSULTANTS, LTD

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1649462037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA CONSULTANTS, LTD

Provider Business Mailing Address
First Line	:	2829 S UNIVERSITY DRIVE
Second Line	:	SUITE 204
City	:	FARGO
State	:	ND
Zip	:	58103
Country	:	US
Telephone Number	:	701-293-9829
Fax Number	:	701-293-0111

Provider Business Practice Location Address
First Line	:	4350 S WASHINGTON ST
Second Line	:	SUITE #112
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-7184
Country	:	US
Telephone Number	:	701-293-9829
Fax Number	:	701-293-0111

Authorized Official
Title or Position	:	ASSISTANT ADMINISTRATIVE MANAGER
Name	:	LAURIE POLKA
Credential	:
Telephone Number	:	701-293-9829

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	09/07/2017

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