Healthcare Provider Details

I. General information

NPI: 1134141153
Provider Name (Legal Business Name): MERITCARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 2ND AVENUE NE
LAMOURE ND
58458
US

IV. Provider business mailing address

107 2ND AVENUE NE
LAMOURE ND
58458
US

V. Phone/Fax

Practice location:
  • Phone: 701-883-5383
  • Fax: 701-883-5113
Mailing address:
  • Phone: 701-883-5383
  • Fax: 701-883-5113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA M CARLSON
Title or Position: PAYOR RELATION COORDINATOR
Credential:
Phone: 701-234-4811