Provider Demographics
NPI:1649462037
Name:RETINA CONSULTANTS, LTD
Entity type:Organization
Organization Name:RETINA CONSULTANTS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-293-9829
Mailing Address - Street 1:2829 S UNIVERSITY DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-293-9829
Mailing Address - Fax:701-293-0111
Practice Address - Street 1:4350 S WASHINGTON ST
Practice Address - Street 2:SUITE #112
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7184
Practice Address - Country:US
Practice Address - Phone:701-293-9829
Practice Address - Fax:701-293-0111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RETINA CONSULTANTS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-10
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN70463Medicare PIN
ND12509Medicaid
MN15009REOtherMN BLUE SHIELD
MN637655000Medicaid
MN9908343OtherMEDICA
ND3174OtherND BLUE SHIELD
NDN70463Medicare PIN