Provider Demographics
NPI:1518047091
Name:FARGO GASTROENTEROLOGY & HEPATOLOGY CLINIC,PC
Entity Type:Organization
Organization Name:FARGO GASTROENTEROLOGY & HEPATOLOGY CLINIC,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AREZOO
Authorized Official - Middle Name:
Authorized Official - Last Name:TAHERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-235-3050
Mailing Address - Street 1:1665 43RD ST S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3319
Mailing Address - Country:US
Mailing Address - Phone:701-235-3050
Mailing Address - Fax:701-235-2224
Practice Address - Street 1:1665 43RD ST S
Practice Address - Street 2:SUITE 100
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3319
Practice Address - Country:US
Practice Address - Phone:701-235-3050
Practice Address - Fax:701-235-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty