Provider Demographics
NPI:1801000294
Name:MID DAKOTA CLINIC MAMMOGRAPHY
Entity Type:Organization
Organization Name:MID DAKOTA CLINIC MAMMOGRAPHY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HEEGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-364-4554
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4530
Mailing Address - Country:US
Mailing Address - Phone:701-530-6000
Mailing Address - Fax:701-530-6430
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4530
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6430
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID DAKOTA CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND125369261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
125369OtherCLIA #
ND70185Medicare ID - Type Unspecified