Healthcare Provider Details

I. General information

NPI: 1215990791
Provider Name (Legal Business Name): NORTHLAND FAMILY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/21/2022
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 32ND AVE S STE D
GRAND FORKS ND
58201-6541
US

IV. Provider business mailing address

PO BOX 5210
GRAND FORKS ND
58206-5210
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-2700
  • Fax: 701-732-2701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateND

VIII. Authorized Official

Name: DR. MARK G PETERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 701-732-2700