Basic Information
| Provider Information | |||||||||
| NPI: | 1851546162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLENCOE REGIONAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 HENNEPIN AVE. NO. | ||||||||
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| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3208647880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 HENNEPIN AVE. NO. | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553361416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208643121 | ||||||||
| FaxNumber: | 3208647880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRABAND | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3208647752 | ||||||||
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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 | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1308930001 | 01 | MN | MEDICARE | OTHER | 909545400 | 05 | MN | MEDICAID | 24Z355 | 01 | MN | MEDICARE | OTHER | 620977700 | 05 | MN | MEDICAID | 241355 | 01 | MN | MEDICARE | OTHER | 245263 | 01 | MN | MEDICARE | OTHER |