Healthcare Provider Details

I. General information

NPI: 1245296078
Provider Name (Legal Business Name): TIOGA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N WELO ST
TIOGA ND
58852-7157
US

IV. Provider business mailing address

PO BOX 159
TIOGA ND
58852-0159
US

V. Phone/Fax

Practice location:
  • Phone: 701-664-3368
  • Fax: 701-664-3300
Mailing address:
  • Phone: 701-664-3368
  • Fax: 701-664-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number9333
License Number StateND

VIII. Authorized Official

Name: RANDALL K. PEDERSON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 701-664-3305