Provider Demographics
NPI:1477720258
Name:BYDAL, MICHAEL J (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BYDAL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GATEWAY DR NE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-2620
Mailing Address - Country:US
Mailing Address - Phone:218-793-0420
Mailing Address - Fax:218-793-0424
Practice Address - Street 1:151 S 4TH ST STE 401
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4715
Practice Address - Country:US
Practice Address - Phone:701-795-3000
Practice Address - Fax:701-795-3050
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN935555300OtherMHCP PROVIDER NUMBER