MEDICARE: NORTHERN NEUROSURGERY AND SPINE PLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1386281475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN NEUROSURGERY AND SPINE PLC

Provider Business Mailing Address
First Line	:	350 23RD AVE E STE 102
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-7401
Country	:	US
Telephone Number	:	701-356-7444
Fax Number	:	855-453-4956

Provider Business Practice Location Address
First Line	:	350 23RD AVE E STE 102
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-7401
Country	:	US
Telephone Number	:	701-356-7444
Fax Number	:	855-453-4956

Authorized Official
Title or Position	:	OWNER
Name	:	STEVEN JARED BROADWAY
Credential	:	MD
Telephone Number	:	701-356-7444

Provider Enumeration Date	:	12/08/2019
Last Update Date	:	01/11/2024

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