Healthcare Provider Details

I. General information

NPI: 1396736443
Provider Name (Legal Business Name): HANS E BJELLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5621 36TH AVE S UNIT 200
FARGO ND
58104-5270
US

IV. Provider business mailing address

5621 36TH AVE S UNIT 200
FARGO ND
58104-5270
US

V. Phone/Fax

Practice location:
  • Phone: 701-977-9898
  • Fax:
Mailing address:
  • Phone: 701-977-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8067
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41143
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: