Provider Demographics
NPI:1972769826
Name:HANS BJELLUM MD PC
Entity type:Organization
Organization Name:HANS BJELLUM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANS
Authorized Official - Middle Name:
Authorized Official - Last Name:BJELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-815-7555
Mailing Address - Street 1:4622 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4394
Mailing Address - Country:US
Mailing Address - Phone:701-232-6211
Mailing Address - Fax:701-364-9346
Practice Address - Street 1:1517 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5905
Practice Address - Country:US
Practice Address - Phone:701-232-6211
Practice Address - Fax:701-364-9346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41143208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty