Provider Demographics
NPI:1336286798
Name:FORT YATES INDIAN HEALTH SERVICE HOSPITAL
Entity Type:Organization
Organization Name:FORT YATES INDIAN HEALTH SERVICE HOSPITAL
Other - Org Name:CANNONBALL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:RHEA
Authorized Official - Last Name:GIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-854-8211
Mailing Address - Street 1:PO BOX J
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0527
Mailing Address - Country:US
Mailing Address - Phone:701-854-3831
Mailing Address - Fax:701-854-7411
Practice Address - Street 1:6998 WEASEL STREET
Practice Address - Street 2:
Practice Address - City:CANNONBALL
Practice Address - State:ND
Practice Address - Zip Code:58528
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:701-854-7411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT YATES INDIAN HEALTH SERVICE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1459056Medicaid
ND001058Medicaid