Healthcare Provider Details

I. General information

NPI: 1902390172
Provider Name (Legal Business Name): TYRONE BERENTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 OHMER ST
BOTTINEAU ND
58318-1045
US

IV. Provider business mailing address

316 OHMER ST
BOTTINEAU ND
58318-1045
US

V. Phone/Fax

Practice location:
  • Phone: 701-228-9400
  • Fax: 701-228-9398
Mailing address:
  • Phone: 701-228-9400
  • Fax: 701-228-9398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number17367
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: