Healthcare Provider Details

I. General information

NPI: 1891151908
Provider Name (Legal Business Name): WALTER LOREN KEMP MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N COLUMBIA RD MAILSTOP 9037, RM. 5933
GRAND FORKS ND
58203-2817
US

IV. Provider business mailing address

501 N COLUMBIA RD MAILSTOP 9037, RM. 5933
GRAND FORKS ND
58203-2817
US

V. Phone/Fax

Practice location:
  • Phone: 701-777-6941
  • Fax:
Mailing address:
  • Phone: 701-777-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number13727
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number10002
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberL5007
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number9509
License Number StateSD
# 5
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number59727
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: