Provider Demographics
NPI:1043378268
Name:CATALYST MEDICAL CENTER PC
Entity type:Organization
Organization Name:CATALYST MEDICAL CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-365-8700
Mailing Address - Street 1:1800 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-365-8700
Mailing Address - Fax:701-365-8701
Practice Address - Street 1:1800 21ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-365-8700
Practice Address - Fax:701-365-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13515Medicaid
MNC04026OtherMN MEDICARE PIN
I37802Medicare UPIN
F38378Medicare UPIN
NDN711497Medicare PIN