MEDICARE: FERGUS FALLS MEDICAL GROUP, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center	44	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00-01587	OTHER	MN	BLC MEDICA #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	115098	OTHER	MN	BLC UCARE #
4	62345FE	OTHER	MN	BLC BCBS #

General Provider Information

NPI Number	:	1376587972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FERGUS FALLS MEDICAL GROUP, P.A.

Provider Business Mailing Address
First Line	:	615 S MILL ST
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2756
Country	:	US
Telephone Number	:	218-739-2221
Fax Number	:	218-739-5501

Provider Business Practice Location Address
First Line	:	410 LAKE AVE S
Second Line	:
City	:	BATTLE LAKE
State	:	MN
Zip	:	56515
Country	:	US
Telephone Number	:	218-864-5283
Fax Number	:	218-864-8452

Authorized Official
Title or Position	:	CEO
Name	:	JIM WILKUS
Credential	:
Telephone Number	:	218-739-2221

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/22/2020

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