Basic Information
Provider Information | |||||||||
NPI: | 1447213202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JYSTAD | ||||||||
FirstName: | PHILIP | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: | 7019523265 | ||||||||
Practice Location | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: | 7019523265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2006 | ||||||||
LastUpdateDate: | 08/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5832 | ND | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 10973 | 01 | ND | BLUE CROSS | OTHER | 16445 | 05 | ND |   | MEDICAID | 3941009 | 01 |   | MEDICA | OTHER | HP42318 | 01 |   | HEALTH PARTNERS | OTHER | 449161007916 | 01 |   | PREFERRED ONE | OTHER |