Healthcare Provider Details

I. General information

NPI: 1164428272
Provider Name (Legal Business Name): NORTH DAKOTA SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 47TH AVE SOUTH
GRAND FORKS ND
58201
US

IV. Provider business mailing address

3035 DEMERS AVE
GRAND FORKS ND
58201-4040
US

V. Phone/Fax

Practice location:
  • Phone: 701-738-4248
  • Fax: 701-775-3153
Mailing address:
  • Phone: 701-738-4240
  • Fax: 701-775-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number35C0001011
License Number StateND

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5935