Provider Demographics
NPI:1770591927
Name:UNDERWOOD CLINIC PC
Entity type:Organization
Organization Name:UNDERWOOD CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIDHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-442-3148
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58576-0253
Mailing Address - Country:US
Mailing Address - Phone:701-442-3148
Mailing Address - Fax:701-442-3414
Practice Address - Street 1:87 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58576
Practice Address - Country:US
Practice Address - Phone:701-442-3148
Practice Address - Fax:701-442-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR25051363LF0000X
NDR25469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13448Medicaid
A63211044293OtherPREFERRED ONE
ND06053002OtherBCBS
ND18607Medicaid
DA6139OtherRR MEDICARE
A63211046001OtherPREFERRED ONE
ND06053001OtherBCBS
NDN711232Medicare PIN