Provider Demographics
NPI:1073897641
Name:BAKER PARK
Entity Type:Organization
Organization Name:BAKER PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:F
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-333-5514
Mailing Address - Street 1:1300 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5103
Mailing Address - Country:US
Mailing Address - Phone:218-333-6514
Mailing Address - Fax:218-333-5566
Practice Address - Street 1:1000 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5109
Practice Address - Country:US
Practice Address - Phone:218-751-0220
Practice Address - Fax:218-333-6514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANFORD HEALTH OF NORTHERN MINNESOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-30
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN349267310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN106240900Medicaid
MN245039Medicare Oscar/Certification
1659376663Medicare NSC