Provider Demographics
NPI:1093752594
Name:BRAINERD STATE HOSPITAL
Entity Type:Organization
Organization Name:BRAINERD STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH ADMIN OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KORNRUMPF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-712-4010
Mailing Address - Street 1:PO BOX 64979
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55164-0979
Mailing Address - Country:US
Mailing Address - Phone:651-431-3691
Mailing Address - Fax:651-431-7505
Practice Address - Street 1:11800 STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-6250
Practice Address - Country:US
Practice Address - Phone:218-828-2201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MINNESOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331059283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087058701Medicaid
MN087058701Medicaid