1700955366 NPI number — GEROPSYCH HEALTH SERVICES, INC.

Table of content: (NPI 1700955366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700955366 NPI number — GEROPSYCH HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEROPSYCH HEALTH SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GEROPSYCH
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700955366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 SPRUCE GROVE LN NW
Provider Second Line Business Mailing Address:
P.O. BOX 155
Provider Business Mailing Address City Name:
BEMIDJI
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56601-7746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-209-1137
Provider Business Mailing Address Fax Number:
218-333-0335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 SPRUCE GROVE LN NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-7746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-209-1137
Provider Business Practice Location Address Fax Number:
218-333-0335
Provider Enumeration Date:
11/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ST. MARTIN
Authorized Official First Name:
SAUNDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-209-1137

Provider Taxonomy Codes

  • Taxonomy code: 364S00000X , with the licence number:  R1077485 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC6885 . This is a "RR MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0199999 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 13481 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014080500 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13481 . This is a "ND DEFINITY" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".