1053308494 NPI number — CITY OF BERTHA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053308494 NPI number — CITY OF BERTHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF BERTHA
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:
1053308494
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
113 2ND AVE NW
Provider Business Mailing Address City Name:
BERTHA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56437-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-924-4454
Provider Business Mailing Address Fax Number:
218-924-4373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 2ND AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERTHA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-924-4454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
UMLAND
Authorized Official First Name:
JANET
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CITY ADMINISTRATOR
Authorized Official Telephone Number:
218-924-4454

Provider Taxonomy Codes

  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 671267300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81208BE . This is a "BC & BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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