Healthcare Provider Details
I. General information
NPI: 1235166323
Provider Name (Legal Business Name): TERRY J BURRELL CNM, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 06/26/2006
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
3000 32ND AVE S
FARGO ND
58103-6132
US
IV. Provider business mailing address
PO BOX 6001
FARGO ND
58108-6001
US
V. Phone/Fax
- Phone: 701-364-8000
- Fax: 701-364-8078
- Phone: 701-364-3300
- Fax: 701-364-8906
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 367A00000X |
| Taxonomy | Advanced Practice Midwife |
| License Number | R20970 |
| License Number State | ND |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | HP25721 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | HEALTHPARTNERS # |
| # 2 | |
| Identifier | 9D421BU |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
| # 3 | |
| Identifier | ND200077 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | LHS # |
| # 4 | |
| Identifier | 12070 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | NDBS # |
| # 5 | |
| Identifier | DA9011015515 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | PREFERRED ONE # |
| # 6 | |
| Identifier | 142324 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | UCARE # |
| # 7 | |
| Identifier | 19500 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 8 | |
| Identifier | 569740900 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 9 | |
| Identifier | 0701575 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 10 | |
| Identifier | 0702337 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MEDICA # |
| # 11 | |
| Identifier | 900339 |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | AMERICA'S PPO/ARAZ # |
| # 12 | |
| Identifier | 9D420BU |
| Identifier Type | OTHER |
| Identifier State | ND |
| Identifier Issuer | MNBS # |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
