1760440846 NPI number — CENTRACARE HEALTH - PAYNESVILLE LLC

Table of content: (NPI 1760440846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760440846 NPI number — CENTRACARE HEALTH - PAYNESVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRACARE HEALTH - PAYNESVILLE LLC
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:
CENTRACARE HEALTH - PAYNESVILLE PHARMACY
Provider Other Organization Name Type Code:
3
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:
1760440846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAYNESVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56362-1445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-243-3767
Provider Business Mailing Address Fax Number:
320-243-7519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYNESVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-243-3767
Provider Business Practice Location Address Fax Number:
320-243-7519
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLAIR
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
SR. VICE PRESIDENT AND CFO
Authorized Official Telephone Number:
320-255-5665

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300173 . This is a "HOSP. UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 333747200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5003780 . This is a "HOSP. MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10141401 . This is a "HOSP. HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03072202705 . This is a "HOSP. PRIMEWEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1006079 . This is a "HOSP. PREF. ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1802HPA . This is a "HOSP & SWING BED BCBS" identifier . This identifiers is of the category "OTHER".




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