Provider Demographics
NPI:1831137389
Name:RICHARD P STADTER PSYCHIATRIC CENTER, LLC
Entity Type:Organization
Organization Name:RICHARD P STADTER PSYCHIATRIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-772-2500
Mailing Address - Street 1:1451 44TH AVE S
Mailing Address - Street 2:PO BOX 14354
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-772-2500
Mailing Address - Fax:701-732-2685
Practice Address - Street 1:1451 44TH AVE S STE A
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-772-2500
Practice Address - Fax:701-787-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5066A283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01426Medicaid
ND12039OtherNDBCBS
MN2F78HRIOtherMNBCBS
MN712617400Medicaid
MN2F78HRIOtherMNBCBS
ND01426Medicaid