Provider Demographics
NPI:1255337861
Name:RED RIVER NEUROLOGY CLINIC
Entity type:Organization
Organization Name:RED RIVER NEUROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORAE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-780-1401
Mailing Address - Street 1:2812 17TH AVE S
Mailing Address - Street 2:STE D
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4048
Mailing Address - Country:US
Mailing Address - Phone:701-780-1401
Mailing Address - Fax:701-780-1404
Practice Address - Street 1:2812 17TH AVE S
Practice Address - Street 2:STE D
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4048
Practice Address - Country:US
Practice Address - Phone:701-780-1401
Practice Address - Fax:701-780-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND42312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16549Medicaid
10389Medicare ID - Type Unspecified
026214Medicare UPIN