Healthcare Provider Details

I. General information

NPI: 1194823021
Provider Name (Legal Business Name): ST. ALEXIUS HEART & LUNG CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N 10TH ST
BISMARCK ND
58501-4516
US

IV. Provider business mailing address

310 N 10TH ST
BISMARCK ND
58501-4516
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-7500
  • Fax: 701-530-7484
Mailing address:
  • Phone: 701-530-7500
  • Fax: 701-530-7484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER A MILLER
Title or Position: PRACTICE DIRECTOR
Credential:
Phone: 701-530-7448