Provider Demographics
NPI:1750326070
Name:FERGUS FALLS MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:FERGUS FALLS MEDICAL GROUP, P.A.
Other - Org Name:BROWN'S VALLEY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-739-2221
Mailing Address - Street 1:615 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2756
Mailing Address - Country:US
Mailing Address - Phone:218-739-2221
Mailing Address - Fax:218-739-5501
Practice Address - Street 1:404 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:BROWN'S VALLEY
Practice Address - State:MN
Practice Address - Zip Code:56219
Practice Address - Country:US
Practice Address - Phone:320-695-8526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FERGUS FALLS MEDICAL GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00-01587OtherBVC MEDICA #
ND10344Medicaid
MN62345FEOtherBVC BCBS #
MN109516OtherBVC UCARE #
ND10344Medicaid
MN62345FEOtherBVC BCBS #