Basic Information
| Provider Information | |||||||||
| NPI: | 1134118250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARY'S REGIONAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOODRICH | ||||||||
| AuthorizedOfficialFirstName: | TANNER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PREISDENT | ||||||||
| AuthorizedOfficialTelephone: | 2188475611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.