Healthcare Provider Details

I. General information

NPI: 1013946276
Provider Name (Legal Business Name): INSTITUTE OF SPECIALTY SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S SUITE H
FARGO ND
58103-6104
US

IV. Provider business mailing address

2301 25TH ST S SUITE H
FARGO ND
58103-6104
US

V. Phone/Fax

Practice location:
  • Phone: 701-271-1045
  • Fax: 701-271-1044
Mailing address:
  • Phone: 701-271-1045
  • Fax: 701-271-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier395014000
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer
# 2
Identifier10846
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MR. TIM HAUGEN
Title or Position: ADMINISTRATOR
Credential: CPA
Phone: 701-271-1045