Provider Demographics
NPI:1679664478
Name:HERSETH, RALPH H (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:H
Last Name:HERSETH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:711 DELMORE DR
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-1365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D48644Medicare UPIN