Healthcare Provider Details

I. General information

NPI: 1831137389
Provider Name (Legal Business Name): RICHARD P STADTER PSYCHIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 44TH AVE S STE A
GRAND FORKS ND
58201-3434
US

IV. Provider business mailing address

1451 44TH AVE S PO BOX 14354
GRAND FORKS ND
58201-3434
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-2500
  • Fax: 701-787-8996
Mailing address:
  • Phone: 701-772-2500
  • Fax: 701-732-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number5066A
License Number StateND

VIII. Authorized Official

Name: DR. THOMAS PETERSON
Title or Position: PRESIDENT/ CHIEF MEDICAL OFFICER
Credential: MD
Phone: 701-772-2500