Basic Information
| Provider Information | |||||||||
| NPI: | 1770637936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST ALEXIUS MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | GREAT PLAINS REHABILITATION SERVICES-MINOT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 BURDICK EXPY E STE 201A | ||||||||
| Address2: | GREAT PLAINS REHABILITATION SERVICES MINOT | ||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018577364 | ||||||||
| FaxNumber: | 7018577419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7015307000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 26027 | 01 | ND | BCBS | OTHER | 50868 | 05 | ND | MEDICAID | 03320003 | 01 | ND | BCBS ND CLINIC # | OTHER |