Provider Demographics
NPI:1649469255
Name:UNIVERSITY OF NORTH DAKOTA
Entity type:Organization
Organization Name:UNIVERSITY OF NORTH DAKOTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-328-9950
Mailing Address - Street 1:515 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4407
Mailing Address - Country:US
Mailing Address - Phone:701-328-9950
Mailing Address - Fax:701-385-9957
Practice Address - Street 1:515 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4407
Practice Address - Country:US
Practice Address - Phone:701-328-9950
Practice Address - Fax:701-328-9957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN6252Medicare PIN