1053342329 NPI number — BRAINERD MEDICAL CENTER INC

Table of content: (NPI 1053342329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053342329 NPI number — BRAINERD MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAINERD MEDICAL CENTER 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:
ESSENTIA HEALTH BRAINERD 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:
1053342329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/03/2021
NPI Reactivation Date:
09/14/2021

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 BELKNAP ST
Provider Second Line Business Mailing Address:
ATN: PHARMACY SERVICES
Provider Business Mailing Address City Name:
SUPERIOR
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54880-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-786-4265
Provider Business Mailing Address Fax Number:
218-786-2198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2024 S 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINERD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56401-4529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-829-7455
Provider Business Practice Location Address Fax Number:
218-855-5205
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOREN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF FINANCE
Authorized Official Telephone Number:
218-786-1009

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , 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)





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