Healthcare Provider Details

I. General information

NPI: 1366484404
Provider Name (Legal Business Name): MID DAKOTA CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4507
US

IV. Provider business mailing address

401 N 9TH ST
BISMARCK ND
58501-4507
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-6100
  • Fax: 701-530-6430
Mailing address:
  • Phone: 701-530-6100
  • Fax: 701-530-6430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number35C1001023
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier35C1001023
Identifier TypeOTHER
Identifier State
Identifier IssuerCMS
# 2
IdentifierP00320159
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMEDICARE RAILROAD
# 3
Identifier13685
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: WILLIAM HEEGAARD
Title or Position: PRESIDENT
Credential:
Phone: 701-364-4554