Healthcare Provider Details

I. General information

NPI: 1396915120
Provider Name (Legal Business Name): NORTHPORT MEDICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 BROADWAY N SUITE C
FARGO ND
58102-1487
US

IV. Provider business mailing address

2704 BROADWAY N SUITE C
FARGO ND
58102-1487
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-3100
  • Fax: 701-232-3135
Mailing address:
  • Phone: 701-232-3100
  • Fax: 701-232-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number6528
License Number StateND

VIII. Authorized Official

Name: DR. HARJINDER K VIRDEE
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 701-232-3100