Healthcare Provider Details

I. General information

NPI: 1669493904
Provider Name (Legal Business Name): SUSAN M VITALIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 BROADWAY N
FARGO ND
58122-0001
US

IV. Provider business mailing address

665 3RD ST SW
PERHAM MN
56573-1108
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4811
  • Fax: 701-234-6979
Mailing address:
  • Phone: 218-347-1200
  • Fax: 218-346-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31744
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: