Healthcare Provider Details

I. General information

NPI: 1417960477
Provider Name (Legal Business Name): MARK J KRISBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S COLUMBIA RD.
GRAND FORKS ND
58201-4028
US

IV. Provider business mailing address

2401 DEMERS AVE - ALTRU BUSINESS CENTER
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6697
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number15038
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: