Healthcare Provider Details

I. General information

NPI: 1255339628
Provider Name (Legal Business Name): BISMARCK SURGICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E GREENFIELD LN
BISMARCK ND
58503-6578
US

IV. Provider business mailing address

106 E GREENFIELD LN
BISMARCK ND
58503-6578
US

V. Phone/Fax

Practice location:
  • Phone: 701-221-2299
  • Fax: 701-323-3388
Mailing address:
  • Phone: 701-221-2299
  • Fax: 701-323-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ATTAS BOUTROUS
Title or Position: ADMINISTRATOR
Credential: MDA
Phone: 701-221-2299