Provider Demographics
NPI:1689836975
Name:MERITCARE MEDICAL GROUP
Entity Type:Organization
Organization Name:MERITCARE MEDICAL GROUP
Other - Org Name:MERITCARE DERMATOLOGY & LASER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-4811
Mailing Address - Street 1:4656 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4394
Mailing Address - Country:US
Mailing Address - Phone:701-234-8860
Mailing Address - Fax:701-234-8924
Practice Address - Street 1:4656 40TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4394
Practice Address - Country:US
Practice Address - Phone:701-234-8860
Practice Address - Fax:701-234-8924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty