Provider Demographics
NPI:1720156664
Name:CENTRAL DAKOTA FAMILY PHYSICIANS, PC
Entity Type:Organization
Organization Name:CENTRAL DAKOTA FAMILY PHYSICIANS, PC
Other - Org Name:CENTRAL DAKOTA CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:NYHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-324-4856
Mailing Address - Street 1:922 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:ND
Mailing Address - Zip Code:58341-1524
Mailing Address - Country:US
Mailing Address - Phone:701-324-4856
Mailing Address - Fax:701-324-4858
Practice Address - Street 1:922 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:ND
Practice Address - Zip Code:58341-1524
Practice Address - Country:US
Practice Address - Phone:701-324-4856
Practice Address - Fax:701-324-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10310Medicaid
0338990001Medicare NSC
NDN6220Medicare ID - Type Unspecified