1720086028 NPI number — CCM HEALTH

Table of content: (NPI 1720086028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720086028 NPI number — CCM HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCM HEALTH
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:
CHIPPEWA COUNTY MONTEVIDEO HOSPITAL
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:
1720086028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
824 N 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTEVIDEO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56265-1629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-269-8877
Provider Business Mailing Address Fax Number:
320-269-8186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 N 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEVIDEO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-269-8877
Provider Business Practice Location Address Fax Number:
320-269-8186
Provider Enumeration Date:
07/11/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ANSPACH
Authorized Official First Name:
DESERAE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
320-269-8877

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X , with the licence number: 327693 , 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: 855345900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".