Provider Demographics
NPI:1184923179
Name:ALISA T MITSKOG, P.C.
Entity type:Organization
Organization Name:ALISA T MITSKOG, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITSKOG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-642-6444
Mailing Address - Street 1:PO BOX 1461
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58074-1461
Mailing Address - Country:US
Mailing Address - Phone:701-642-6444
Mailing Address - Fax:
Practice Address - Street 1:319 11TH ST N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4111
Practice Address - Country:US
Practice Address - Phone:701-642-6444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND500261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center