Provider Demographics
NPI:1740254523
Name:TIOGA MEDICAL CENTER
Entity type:Organization
Organization Name:TIOGA MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-664-3305
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:TIOGA
Mailing Address - State:ND
Mailing Address - Zip Code:58852-0159
Mailing Address - Country:US
Mailing Address - Phone:701-664-3305
Mailing Address - Fax:701-664-2240
Practice Address - Street 1:MAIN STREET
Practice Address - Street 2:
Practice Address - City:POWERS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58773
Practice Address - Country:US
Practice Address - Phone:701-464-5668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND8557OtherBCBSND
ND5023Medicaid
ND35-3987Medicare ID - Type UnspecifiedND MEDICARE