Provider Demographics
NPI:1659620110
Name:FARGO PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:FARGO PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEG
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-499-4807
Mailing Address - Street 1:3280 20TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5917
Mailing Address - Country:US
Mailing Address - Phone:701-293-7480
Mailing Address - Fax:701-235-2099
Practice Address - Street 1:3280 20TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5917
Practice Address - Country:US
Practice Address - Phone:701-293-7480
Practice Address - Fax:701-235-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT 12481208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty