MEDICARE: BRIAN V JONGEWARD

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	611	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1407909120	OTHER	ND	CLINIC NPI
3	1376620831	OTHER	ND	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1407909120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIAN V JONGEWARD

Provider Business Mailing Address
First Line	:	2812 17TH AVE S STE C
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-775-0223
Fax Number	:	701-738-0655

Provider Business Practice Location Address
First Line	:	2812 17TH AVE S STE C
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-775-0223
Fax Number	:	701-738-0655

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. BRIAN V JONGEWARD
Credential	:	DC
Telephone Number	:	701-775-0223

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	02/21/2008

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