1730110115 NPI number — ST MARY'S INNOVIS HEALTH

Table of content: DR. PATRICK V HICKLE MD (NPI 1346218609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730110115 NPI number — ST MARY'S INNOVIS HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST MARY'S INNOVIS 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:
ESSENTIA HEALTH DETROIT LAKES 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:
1730110115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 FRAZEE STREET EAST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-847-3537
Provider Business Mailing Address Fax Number:
218-847-4405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 FRAZEE STREET EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-3537
Provider Business Practice Location Address Fax Number:
218-847-4405
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HURLEY
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
701-364-7667

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  263266 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 263266 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 263266 , 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: 290678000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2409995 . This is a "NABP NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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