Basic Information
| Provider Information | |||||||||
| NPI: | 1598792939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILBERTSON | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346960 | ||||||||
| FaxNumber: | 7012346979 | ||||||||
| Practice Location | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012346960 | ||||||||
| FaxNumber: | 7012346979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 3152 | ND | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 16575 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4617 | 01 | NDBC | OTHER | HP10479 | 01 | HEALTHPARTNERS | OTHER | 12364 | 05 | ND | MEDICAID | 1624696 | 01 | MEDICA | OTHER | 895001 | 01 | PREFERRED ONE | OTHER | 90926GI | 01 | MNBC | OTHER |