Basic Information
| Provider Information | |||||||||
| NPI: | 1891721841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIBETO | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 15TH AVE. W. | ||||||||
| Address2: | MERCY MEDICAL CENTER | ||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747400 | ||||||||
| FaxNumber: | 7015721688 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 15TH AVE. W. | ||||||||
| Address2: | CRAVEN HAGAN CLINIC | ||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727651 | ||||||||
| FaxNumber: | 7015721688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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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 | 208600000X | 48079 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 10618 | ND | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 13464 | 05 | MN | MEDICAID | 137084 | 01 | MN | UCARE # | OTHER | DA9021044154 | 01 | MN | PREFERRED ONE # | OTHER | 2366070 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 25809 | 01 | MN | NDBS # | OTHER | 44377 | 01 | MN | LHS # | OTHER | 1701454 | 01 | MN | MEDICA # | OTHER | 317S5VI | 01 | MN | MNBS # | OTHER | 440683400 | 05 | MN | MEDICAID | HP53212 | 01 | MN | HEALTHPARTNERS # | OTHER |