Healthcare Provider Details

I. General information

NPI: 1578594016
Provider Name (Legal Business Name): REGIONAL MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 TWIN CITY DR
MANDAN ND
58554-3820
US

IV. Provider business mailing address

2008 TWIN CITY DR
MANDAN ND
58554-3820
US

V. Phone/Fax

Practice location:
  • Phone: 701-667-1000
  • Fax: 701-667-0707
Mailing address:
  • Phone: 701-667-1000
  • Fax: 701-667-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4124
License Number StateND

VIII. Authorized Official

Name: VICKI L BOEHM
Title or Position: BUSINESS MANAGER
Credential:
Phone: 701-667-1022