Provider Demographics
NPI:1427152115
Name:NORTH DAKOTA STATE UNIVERSITY
Entity type:Organization
Organization Name:NORTH DAKOTA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-231-5239
Mailing Address - Street 1:PO BOX 6050 NDSU DEPT. 5150
Mailing Address - Street 2:NDSU STUDENT HEALTH SERVICE
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6050
Mailing Address - Country:US
Mailing Address - Phone:701-231-7331
Mailing Address - Fax:701-231-6132
Practice Address - Street 1:1707 CENTENNIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-231-7331
Practice Address - Fax:701-231-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND168183500000X
261Q00000X
ND95503681291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13139Medicaid