Basic Information
| Provider Information | |||||||||
| NPI: | 1801000294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID DAKOTA CLINIC MAMMOGRAPHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015306000 | ||||||||
| FaxNumber: | 7015306430 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015306000 | ||||||||
| FaxNumber: | 7015306430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | HEEGAARD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7013644554 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID DAKOTA CLINIC, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | 125369 | ND | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
ID Information
| ID | Type | State | Issuer | Description | 125369 | 01 | CLIA # | OTHER |