Provider Demographics
NPI:1528452927
Name:MATTHEW R. DEROSIER, PLLC
Entity type:Organization
Organization Name:MATTHEW R. DEROSIER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DEROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-214-6245
Mailing Address - Street 1:5108 37TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-1188
Mailing Address - Country:US
Mailing Address - Phone:701-204-7701
Mailing Address - Fax:701-222-3645
Practice Address - Street 1:1921 N 13TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1973
Practice Address - Country:US
Practice Address - Phone:701-222-2252
Practice Address - Fax:701-222-3645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10761Medicaid
ND30063OtherBCBS-ND
ND30063OtherBCBS-ND