Provider Demographics
NPI:1285821314
Name:UPPER MISSISSIPPI SURGICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:UPPER MISSISSIPPI SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MA
Authorized Official - Last Name:FORTIER
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:320-749-2607
Mailing Address - Street 1:9264 HIGHWAY 115
Mailing Address - Street 2:
Mailing Address - City:RANDALL
Mailing Address - State:MN
Mailing Address - Zip Code:56475-2501
Mailing Address - Country:US
Mailing Address - Phone:320-749-2607
Mailing Address - Fax:320-749-8301
Practice Address - Street 1:9264 HIGHWAY 115
Practice Address - Street 2:
Practice Address - City:RANDALL
Practice Address - State:MN
Practice Address - Zip Code:56475-2501
Practice Address - Country:US
Practice Address - Phone:320-749-2607
Practice Address - Fax:320-749-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34195174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02675Medicare UPIN