Healthcare Provider Details

I. General information

NPI: 1578501672
Provider Name (Legal Business Name): BYRON ALAN VELANDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 44TH AVENUE SOUTH SUITE #112-D
GRAND FORKS ND
58201
US

IV. Provider business mailing address

1451 44TH AVENUE SOUTH SUITE #112D
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-775-5800
  • Fax: 701-775-5200
Mailing address:
  • Phone: 701-775-5800
  • Fax: 701-775-5200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number036-111489
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number112716
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number11312
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: