Healthcare Provider Details

I. General information

NPI: 1750355533
Provider Name (Legal Business Name): MICHAEL BLACKSMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 8TH AVE NE
HAZEN ND
58545-4638
US

IV. Provider business mailing address

322 7TH AVE NW
HAZEN ND
58545-4108
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2256
  • Fax: 701-748-2257
Mailing address:
  • Phone: 701-748-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9158
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: