1558435131 NPI number — GRAND ITASCA CLINIC AND HOSPITAL

Table of content: (NPI 1558435131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558435131 NPI number — GRAND ITASCA CLINIC AND HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND ITASCA CLINIC AND HOSPITAL
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:
Provider Other Organization Name Type Code:
6
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:
1558435131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 GOLF COURSE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744-8648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-999-1055
Provider Business Mailing Address Fax Number:
218-999-1052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 SE 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-3663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-999-1055
Provider Business Practice Location Address Fax Number:
218-999-1052
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACDONELL
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
218-999-1510

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 247286 . This is a "HUMANA GOLD CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 247286 . This is a "IMCARE CLASSICS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5B36AIT . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 885525100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 247286 . This is a "UNICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 59-00055 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 885525100 . This is a "IMCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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