Provider Demographics
NPI:1003929944
Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Entity Type:Organization
Organization Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Other - Org Name:GLEN ULLIN FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:OPDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-584-2792
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:ND
Mailing Address - Zip Code:58533-0367
Mailing Address - Country:US
Mailing Address - Phone:701-584-2792
Mailing Address - Fax:
Practice Address - Street 1:602 ASH AVE E
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58631
Practice Address - Country:US
Practice Address - Phone:701-584-2792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5177Medicaid
ND06043003OtherBLUE CROSS - RHC
ND5177Medicaid