Healthcare Provider Details

I. General information

NPI: 1255951984
Provider Name (Legal Business Name): EHINOR EDMOND ISIDAHOME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 DEMERS AVE
GRAND FORKS ND
58201-4040
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-7521
  • Fax: 701-795-2553
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number326754
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number24766
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: