Provider Demographics
NPI:1427466630
Name:MICHIGAN COMMUNITY MEDICAL CLINIC
Entity type:Organization
Organization Name:MICHIGAN COMMUNITY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-259-2118
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:115 SO ST. # 290
Mailing Address - City:MICHIGAN
Mailing Address - State:ND
Mailing Address - Zip Code:58259
Mailing Address - Country:US
Mailing Address - Phone:701-259-2118
Mailing Address - Fax:701-259-2319
Practice Address - Street 1:115 SO ST. # 290
Practice Address - Street 2:
Practice Address - City:MICHIGAN
Practice Address - State:ND
Practice Address - Zip Code:58259
Practice Address - Country:US
Practice Address - Phone:701-259-2118
Practice Address - Fax:701-259-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3113261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11257Medicaid
ND11257Medicaid