Healthcare Provider Details

I. General information

NPI: 1285943746
Provider Name (Legal Business Name): ORTHOPEDIC AND SPORT MEDICINE SPECIALISTS OF FARGO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 UNIVERSITY DR S SUITE 2
FARGO ND
58103-6050
US

IV. Provider business mailing address

2829 UNIVERSITY DR S SUITE 2
FARGO ND
58103-6050
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-0307
  • Fax:
Mailing address:
  • Phone: 701-478-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILIP Q JOHNSON
Title or Position: OWNER
Credential: M.D.
Phone: 701-478-0307