Basic Information
Provider Information | |||||||||
NPI: | 1356511661 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MID DAKOTA CLINIC WORKLIFE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2700 STATE ST | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585030669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015306400 | ||||||||
FaxNumber: | 7015306430 | ||||||||
Practice Location | |||||||||
Address1: | 401 N 9TH ST | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585014530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015306010 | ||||||||
FaxNumber: | 7015306430 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2008 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEEGAARD | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7013644554 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MID DAKOTA CLINIC, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
ID | Type | State | Issuer | Description | 236003 | 01 | ND | BCBSND | OTHER |