Provider Demographics
NPI:1164647822
Name:GRAND FORKS FOOT AND ANKLE CLINIC, PLLC
Entity Type:Organization
Organization Name:GRAND FORKS FOOT AND ANKLE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CARLYLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:701-738-2770
Mailing Address - Street 1:1451 44TH AVE S STE 128D
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-738-2770
Mailing Address - Fax:
Practice Address - Street 1:1451 44TH AVE S STE 128D
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-738-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND48213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND06740-001OtherBLURE CROSS BLUE SHIELD
ND13707Medicaid
ND5651050001Medicare NSC
ND13707Medicaid