Provider Demographics
NPI:1275587826
Name:MID DAKOTA CLINIC, INC.
Entity Type:Organization
Organization Name:MID DAKOTA CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HEEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-364-4554
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4507
Mailing Address - Country:US
Mailing Address - Phone:701-712-4500
Mailing Address - Fax:701-712-4011
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4507
Practice Address - Country:US
Practice Address - Phone:701-712-4500
Practice Address - Fax:701-712-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11238Medicaid
ND0857780001Medicare NSC
NDN6201Medicare ID - Type Unspecified