=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366484404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID DAKOTA CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 10/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N 9TH ST
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58501-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-530-6100
-----------------------------------------------------
Fax | 701-530-6430
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N 9TH ST
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58501-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-530-6100
-----------------------------------------------------
Fax | 701-530-6430
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM HEEGAARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-364-4554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 35C1001023
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------