=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497804082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED RIVER PLASTIC SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 01/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 CENTRAL AVE NE
-----------------------------------------------------
City | EAST GRAND FORKS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56721-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-773-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1428 CENTRAL AVE NE
-----------------------------------------------------
City | EAST GRAND FORKS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56721-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-773-1390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JUDSON CROW
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 866-773-1390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------