Provider Demographics
NPI:1053595223
Name:MARK W PEWE
Entity type:Organization
Organization Name:MARK W PEWE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-228-2275
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-0059
Mailing Address - Country:US
Mailing Address - Phone:701-228-2275
Mailing Address - Fax:701-228-3080
Practice Address - Street 1:909 11 ST E
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318
Practice Address - Country:US
Practice Address - Phone:701-228-2275
Practice Address - Fax:701-228-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND415111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10276Medicaid
ND14716Medicaid
ND4240Medicare PIN
ND10276Medicaid