MEDICARE: ST SOPHIE'S, LLC

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	2084P0800X	Psychiatry Physician	7174	ND

General Provider Information

NPI Number	:	1679916621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST SOPHIE'S, LLC

Provider Business Mailing Address
First Line	:	3120 25TH ST S STE Z
Second Line	:	#344
City	:	FARGO
State	:	ND
Zip	:	58103-6164
Country	:	US
Telephone Number	:	701-365-4467
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 N 14TH ST
Second Line	:	STE 2A
City	:	BISMARCK
State	:	ND
Zip	:	58503-0697
Country	:	US
Telephone Number	:	701-365-4467
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	EMMET KENNEY
Credential	:	MD
Telephone Number	:	701-365-4488

Provider Enumeration Date	:	04/09/2013
Last Update Date	:	04/09/2013

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