Healthcare Provider Details

I. General information

NPI: 1427152115
Provider Name (Legal Business Name): NORTH DAKOTA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 CENTENNIAL BOULEVARD
FARGO ND
58102
US

IV. Provider business mailing address

PO BOX 6050 NDSU DEPT. 5150 NDSU STUDENT HEALTH SERVICE
FARGO ND
58108-6050
US

V. Phone/Fax

Practice location:
  • Phone: 701-231-7331
  • Fax: 701-231-6132
Mailing address:
  • Phone: 701-231-7331
  • Fax: 701-231-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number95503681
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number168
License Number StateND

VIII. Authorized Official

Name: TERI LYNN SHEPHERD
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 701-231-5239