Healthcare Provider Details

I. General information

NPI: 1528130127
Provider Name (Legal Business Name): NORTHERN PLAINS RADIATION ONCOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 15TH AVE W
WILLISTON ND
58801-3821
US

IV. Provider business mailing address

PO BOX 21
WILLISTON ND
58802-0021
US

V. Phone/Fax

Practice location:
  • Phone: 701-572-0988
  • Fax: 701-774-2021
Mailing address:
  • Phone: 701-572-0988
  • Fax: 701-774-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier10770
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier01237001
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: DR. LYLE M. HARRISON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-572-0988