Provider Demographics
NPI:1497804082
Name:RED RIVER PLASTIC SURGERY CENTER
Entity Type:Organization
Organization Name:RED RIVER PLASTIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:
Authorized Official - Last Name:CROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-773-1390
Mailing Address - Street 1:1428 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1605
Mailing Address - Country:US
Mailing Address - Phone:866-773-1390
Mailing Address - Fax:
Practice Address - Street 1:1428 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1605
Practice Address - Country:US
Practice Address - Phone:866-773-1390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13088Medicaid
6296OtherBCBS ND
MN440R4REOtherBCBS MN
MNC03614Medicare PIN
ND13088Medicaid