Healthcare Provider Details

I. General information

NPI: 1699903930
Provider Name (Legal Business Name): BRANDON C SPEIDEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA RD - ALTRU HOSPITAL
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5246
  • Fax: 402-559-1011
Mailing address:
  • Phone: 701-780-1891
  • Fax: 402-559-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number59265
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number13566
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: