Provider Demographics
NPI:1215990791
Name:NORTHLAND FAMILY PHYSICIANS LLC
Entity type:Organization
Organization Name:NORTHLAND FAMILY PHYSICIANS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-732-2700
Mailing Address - Street 1:PO BOX 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 32ND AVE S STE D
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6541
Practice Address - Country:US
Practice Address - Phone:701-732-2700
Practice Address - Fax:701-732-2701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13638Medicaid
MN057629800Medicaid
ND6692001OtherBCBS OF ND
MN269P4NOOtherBCBS OF MN
ND13638Medicaid