Provider Demographics
NPI:1649244617
Name:TIOGA MEDICAL CENTER
Entity Type:Organization
Organization Name:TIOGA MEDICAL CENTER
Other - Org Name:TIOGA MEDICAL CENTER LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-664-3305
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:TIOGA
Mailing Address - State:ND
Mailing Address - Zip Code:58852-0159
Mailing Address - Country:US
Mailing Address - Phone:701-664-3305
Mailing Address - Fax:701-664-2240
Practice Address - Street 1:810 N WELO ST
Practice Address - Street 2:
Practice Address - City:TIOGA
Practice Address - State:ND
Practice Address - Zip Code:58852-7157
Practice Address - Country:US
Practice Address - Phone:701-664-3305
Practice Address - Fax:701-664-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1051A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1016OtherBCBSND
ND30176Medicaid
ND355034Medicare ID - Type UnspecifiedND MEDICARE