Healthcare Provider Details

I. General information

NPI: 1801092358
Provider Name (Legal Business Name): GREAT PLAINS CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 9TH ST W
DICKINSON ND
58601-3950
US

IV. Provider business mailing address

33 9TH ST W
DICKINSON ND
58601-3950
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-6017
  • Fax: 701-483-5018
Mailing address:
  • Phone: 701-483-6017
  • Fax: 701-483-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BECKY S ROSHAU
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 701-456-5115