NPIMap

Organization Active NPI

Custom Clinic, P.a.

Doing business as Smart Clinic

  • Family Medicine Physician
  • Fairmont, MN
National Provider Identifier
1699859124
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CUSTOM CLINIC, P.A.
Doing business as
Smart Clinic
Practice address
322 S State St
5 Lake Center Drive
Fairmont, MN 56031-4139
Phone
(507) 236-2880
NPI assigned
Oct 24, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy C Bachenberg, M.D.NPI 1093799603
Title
President
Phone
(507) 236-2880

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

322 S State St
5 Lake Center Drive
Fairmont, MN 56031-4139

Mailing address

322 S State St
5 Lake Center Drive
Fairmont, MN 56031-4139
Phone (507) 236-2880

Other names 1

  • Smart Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070403000140 MN Part B Supplier - Clinic/Group Practice 2961506860 Receives reassigned benefits from 2 practitioners
Practice locations: Fairmont, MN; Trimont, MN

National Provider Directory

National Provider Directory

Locations

322 S State St
#5
Fairmont, MN 56031
Phone (507) 236-2880

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1699859124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "322 S STATE ST",
            "address_2": "5 LAKE CENTER DRIVE",
            "city": "FAIRMONT",
            "state": "MN",
            "postal_code": "560314139",
            "telephone_number": "507-236-2880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "322 S STATE ST",
            "address_2": "5 LAKE CENTER DRIVE",
            "city": "FAIRMONT",
            "state": "MN",
            "postal_code": "560314139",
            "telephone_number": "507-236-2880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM CLINIC, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-24",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BACHENBERG",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "507-236-2880",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Smart Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fairmont, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.