MEDICARE: MERITCARE MEDICAL GROUP

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1689836975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERITCARE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4656 40TH AVE S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-4394
Country	:	US
Telephone Number	:	701-234-8860
Fax Number	:	701-234-8924

Provider Business Practice Location Address
First Line	:	4656 40TH AVE S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-4394
Country	:	US
Telephone Number	:	701-234-8860
Fax Number	:	701-234-8924

Authorized Official
Title or Position	:	CFO
Name	:	LISA M CARLSON
Credential	:
Telephone Number	:	701-234-4811

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	11/27/2023

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