Provider Demographics
NPI:1578594016
Name:REGIONAL MEDICAL CENTER PC
Entity Type:Organization
Organization Name:REGIONAL MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-667-1022
Mailing Address - Street 1:2008 TWIN CITY DR
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3820
Mailing Address - Country:US
Mailing Address - Phone:701-667-1000
Mailing Address - Fax:701-667-0707
Practice Address - Street 1:2008 TWIN CITY DR
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3820
Practice Address - Country:US
Practice Address - Phone:701-667-1000
Practice Address - Fax:701-667-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1051140001OtherDMERC CIGNA
SD7709620OtherSD MEDICAID
NDC52498OtherPALMETTO GBA
ND13249Medicaid
ND1051140001OtherDMERC CIGNA
SD7709620OtherSD MEDICAID