Basic Information
| Provider Information | |||||||||
| NPI: | 1457393035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST MARYS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH ST MARYS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 407 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOREN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2187861009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. MARY'S DULUTH CLINIC HEALTH SYSTEM | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 338732 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 282N00000X | 331095 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1457393035 | 05 | MN | MEDICAID |