Provider Demographics
NPI:1043601065
Name:RAYMOND L. LARSEN, MD
Entity type:Organization
Organization Name:RAYMOND L. LARSEN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GROUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-252-9020
Mailing Address - Street 1:916 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3437
Mailing Address - Country:US
Mailing Address - Phone:701-252-9020
Mailing Address - Fax:701-252-2209
Practice Address - Street 1:916 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3437
Practice Address - Country:US
Practice Address - Phone:701-252-9020
Practice Address - Fax:701-252-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10092Medicaid