Healthcare Provider Details

I. General information

NPI: 1083229082
Provider Name (Legal Business Name): ROBERT JOSEPH BUZICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 DEMERS AVE
GRAND FORKS ND
58201-4528
US

IV. Provider business mailing address

523 DEMERS AVE
GRAND FORKS ND
58201-4528
US

V. Phone/Fax

Practice location:
  • Phone: 701-354-1387
  • Fax:
Mailing address:
  • Phone: 701-354-1387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26214
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5553
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: