Healthcare Provider Details

I. General information

NPI: 1164514519
Provider Name (Legal Business Name): SUNANDA JAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E BROADWAY AVE
BISMARCK ND
58501-4520
US

IV. Provider business mailing address

PO BOX 997
BISMARCK ND
58502-0997
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-7000
  • Fax: 701-530-6536
Mailing address:
  • Phone: 701-530-6500
  • Fax: 701-530-6536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number9177
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: