Provider Demographics
NPI:1619905528
Name:UNIVERSITY OF NORTH DAKOTA
Entity Type:Organization
Organization Name:UNIVERSITY OF NORTH DAKOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRVIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-751-6753
Mailing Address - Street 1:701 E. ROSSER AVE.
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4461
Mailing Address - Country:US
Mailing Address - Phone:701-751-9500
Mailing Address - Fax:701-751-9508
Practice Address - Street 1:701 E. ROSSER AVE.
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4461
Practice Address - Country:US
Practice Address - Phone:701-328-9950
Practice Address - Fax:701-328-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-SurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1459002Medicaid
ND12083Medicaid
ND102001OtherBCBS
ND12083Medicaid
ND1459002Medicaid