Basic Information
| Provider Information | |||||||||
| NPI: | 1992869770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NELSON COUNTY HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 108 E NYHUS AVE | ||||||||
| Address2: | |||||||||
| City: | MCVILLE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582544110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013224314 | ||||||||
| FaxNumber: | 7013225533 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 E NYHUS AVE | ||||||||
| Address2: | |||||||||
| City: | MCVILLE | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582544110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013224314 | ||||||||
| FaxNumber: | 7013225533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWERSOX | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7013224328 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1040B | ND | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 030384 | 05 | ND | MEDICAID | 001263 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER |