Provider Demographics
NPI:1013946276
Name:INSTITUTE OF SPECIALTY SURGERY LLC
Entity Type:Organization
Organization Name:INSTITUTE OF SPECIALTY SURGERY LLC
Other - Org Name:INSTITUTE FOR SPECIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:701-271-1045
Mailing Address - Street 1:2301 25TH ST S
Mailing Address - Street 2:SUITE H
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6104
Mailing Address - Country:US
Mailing Address - Phone:701-271-1045
Mailing Address - Fax:701-271-1044
Practice Address - Street 1:2301 25TH ST S
Practice Address - Street 2:SUITE H
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-271-1045
Practice Address - Fax:701-271-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN395014000Medicaid
ND10846Medicaid
NDN8617Medicare ID - Type Unspecified