Basic Information
Provider Information | |||||||||
NPI: | 1861553844 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. ALEXIUS MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHI ST. ALEXIUS HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5510 | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585065510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015307000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 FAIRWAY ST | ||||||||
Address2: |   | ||||||||
City: | DICKINSON | ||||||||
State: | ND | ||||||||
PostalCode: | 586012639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7014564616 | ||||||||
FaxNumber: | 7014564803 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 05/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRIS | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7015307000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CATHOLIC HEALTH INITIATIVES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 5004 | ND | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
ID | Type | State | Issuer | Description | 1460486 | 05 | ND |   | MEDICAID |