Provider Demographics
NPI:1083910699
Name:ST. JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST. JOSEPH'S - HACKENSACK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-828-8764
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:
Practice Address - Street 1:110 3RD ST. S
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:MN
Practice Address - Zip Code:56452-0485
Practice Address - Country:US
Practice Address - Phone:218-675-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH'S MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site