Provider Demographics
NPI:1134167166
Name:FERGUS FALLS MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:FERGUS FALLS MEDICAL GROUP, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:405 MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHBY
Practice Address - State:MN
Practice Address - Zip Code:56309-4659
Practice Address - Country:US
Practice Address - Phone:218-747-2293
Practice Address - Fax:218-747-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00-01587OtherAC MEDICA #
MN126702OtherAC UCARE #
MN62345FEOtherAC BCBS #
MN62345FEOtherAC BCBS #