Provider Demographics
NPI:1093152423
Name:DEER RIVER HEALTHCARE CENTER, INC.
Entity Type:Organization
Organization Name:DEER RIVER HEALTHCARE CENTER, INC.
Other - Org Name:ESSENTIA HEALTH GRAND RAPIDS CLNIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER-REVENUE INTEGRITY
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-246-3047
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3555
Mailing Address - Country:US
Mailing Address - Phone:218-999-7099
Mailing Address - Fax:218-999-7099
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3555
Practice Address - Country:US
Practice Address - Phone:218-999-7099
Practice Address - Fax:218-999-7099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-24
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN361503261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093152423Medicaid
MNC06025Medicare PIN
MN241360Medicare Oscar/Certification