Provider Demographics
NPI:1831312750
Name:RED RIVER FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:RED RIVER FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANTELL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TWOBEARS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-499-4340
Mailing Address - Street 1:300 MAIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1930
Mailing Address - Country:US
Mailing Address - Phone:701-499-4340
Mailing Address - Fax:701-499-4341
Practice Address - Street 1:300 MAIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1930
Practice Address - Country:US
Practice Address - Phone:701-499-4340
Practice Address - Fax:701-499-4341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7807207Q00000X
NDR28446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN931G4REOtherBLUE CROSS BLUE SHIELD
98-98110OtherMEDICA
13172OtherHEALTHPARTNERS
ND14245Medicaid
ND06960/001OtherBLUE CROSS BLUE SHIELD
ND14245Medicaid