Provider Demographics
NPI:1326130055
Name:NORTHEAST EYE CENTER PC
Entity Type:Organization
Organization Name:NORTHEAST EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-662-4085
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-0130
Mailing Address - Country:US
Mailing Address - Phone:701-662-4085
Mailing Address - Fax:701-662-6010
Practice Address - Street 1:404 HWY 2 E
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-0130
Practice Address - Country:US
Practice Address - Phone:701-662-4085
Practice Address - Fax:701-662-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
05557001OtherBLUE CROSS BLUE SHIELD ND
CJ5092OtherMEDICARE RETIRED RAILROAD
2F903DOOtherBLUE SHIELD MN
ND17954Medicaid
2F903DOOtherBLUE SHIELD MN