Basic Information
| Provider Information | |||||||||
| NPI: | 1700162328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRAINERD MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ESSENTIA HEALTH - BAXTER SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13060 ISLE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13060 ISLE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188282880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2011 | ||||||||
| LastUpdateDate: | 05/01/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2188287656 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRAINERD MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.