Provider Demographics
NPI:1265026165
Name:BISMARCK DERMATOLOGY CENTER PC
Entity Type:Organization
Organization Name:BISMARCK DERMATOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-220-4858
Mailing Address - Street 1:4207 BOULDER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-6163
Mailing Address - Country:US
Mailing Address - Phone:701-673-3376
Mailing Address - Fax:
Practice Address - Street 1:4207 BOULDER RIDGE RD
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-6163
Practice Address - Country:US
Practice Address - Phone:701-673-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1952360711OtherNPI