=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346405602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK M BRICKNER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2008
-----------------------------------------------------
Last Update Date | 03/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 2ND AVE NE
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401-3373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-251-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 2ND AVE NE
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58401-3373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-251-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TEP5877
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 11895
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------