Healthcare Provider Details

I. General information

NPI: 1487814356
Provider Name (Legal Business Name): BISMARCK SURGICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
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: 701-355-4331
Mailing address:
  • Phone: 701-221-2299
  • Fax: 701-323-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR28938
License Number StateND

VIII. Authorized Official

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