Healthcare Provider Details

I. General information

NPI: 1619119591
Provider Name (Legal Business Name): MIDGARDEN FAMILY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 06/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 PARK ST W
PARK RIVER ND
58270-4103
US

IV. Provider business mailing address

503 PARK ST W
PARK RIVER ND
58270-4103
US

V. Phone/Fax

Practice location:
  • Phone: 701-284-6663
  • Fax: 701-284-6923
Mailing address:
  • Phone: 701-284-6663
  • Fax: 701-284-6923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number8012
License Number StateND

VIII. Authorized Official

Name: DR. KRISTI JEAN MIDGARDEN
Title or Position: OWNER
Credential: M.D.
Phone: 701-284-6663