Provider Demographics
NPI:1043245921
Name:ST. MARY'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. MARY'S MEDICAL CENTER
Other - Org Name:ST. MARY'S HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICE AND ADM.
Authorized Official - Prefix:
Authorized Official - First Name:MARIBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-4878
Mailing Address - Street 1:516 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1936
Mailing Address - Country:US
Mailing Address - Phone:218-786-4004
Mailing Address - Fax:
Practice Address - Street 1:516 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1936
Practice Address - Country:US
Practice Address - Phone:218-786-4004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330709251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN247129Medicare Oscar/Certification