Provider Demographics
NPI:1134141153
Name:MERITCARE MEDICAL GROUP
Entity Type:Organization
Organization Name:MERITCARE MEDICAL GROUP
Other - Org Name:MERITCARE LAMOURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAYOR RELATION COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-4811
Mailing Address - Street 1:107 2ND AVENUE NE
Mailing Address - Street 2:
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58458
Mailing Address - Country:US
Mailing Address - Phone:701-883-5383
Mailing Address - Fax:701-883-5113
Practice Address - Street 1:107 2ND AVENUE NE
Practice Address - Street 2:
Practice Address - City:LAMOURE
Practice Address - State:ND
Practice Address - Zip Code:58458
Practice Address - Country:US
Practice Address - Phone:701-883-5383
Practice Address - Fax:701-883-5113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND353818Medicare Oscar/Certification