Provider Demographics
NPI:1811162811
Name:FAIRLIGHT MEDICAL CENTER
Entity type:Organization
Organization Name:FAIRLIGHT MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESZEK
Authorized Official - Middle Name:J
Authorized Official - Last Name:JASZCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-577-6337
Mailing Address - Street 1:3 EAST 4TH STREET
Mailing Address - Street 2:PO BOX 1148
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-1148
Mailing Address - Country:US
Mailing Address - Phone:701-577-6337
Mailing Address - Fax:701-577-4867
Practice Address - Street 1:3 4TH ST E
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5350
Practice Address - Country:US
Practice Address - Phone:701-577-6337
Practice Address - Fax:701-577-4867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLISTON RADIOLOGY CONSULTANTS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-30
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6414261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND109956169OtherDUNS
ND269-961-7243OtherTPIN
ND621-111OtherNAICS
ND010182Medicaid
MT0406731Medicaid
NDN6228Medicare PIN