Provider Demographics
NPI:1487814356
Name:BISMARCK SURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:BISMARCK SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ATTAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTROUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-221-2299
Mailing Address - Street 1:106 E GREENFIELD LN
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-6578
Mailing Address - Country:US
Mailing Address - Phone:701-221-2299
Mailing Address - Fax:701-323-3338
Practice Address - Street 1:106 E GREENFIELD LN
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-6578
Practice Address - Country:US
Practice Address - Phone:701-221-2299
Practice Address - Fax:701-355-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261QA1903X
NDR28938367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND8618OtherBCBS
ND10864Medicaid
ND490004061OtherRAILROAD MEDICARE
NDN70934Medicare PIN