Provider Demographics
NPI:1134304231
Name:COOPERSTOWN MEDICAL CENTER
Entity Type:Organization
Organization Name:COOPERSTOWN MEDICAL CENTER
Other - Org Name:DAKOTA REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN ASSISTANT/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-786-1709
Mailing Address - Street 1:107 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-4501
Mailing Address - Country:US
Mailing Address - Phone:701-789-1700
Mailing Address - Fax:701-786-7121
Practice Address - Street 1:107 12TH ST S
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-4501
Practice Address - Country:US
Practice Address - Phone:701-786-1700
Practice Address - Fax:701-786-7121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOPERSTOWN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-08
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1009Medicaid
ND21295OtherBLUE CROSS/BLUE SHEILD OF
ND30095Medicaid
ND489OtherBLUE CROSS/BLUE SHIELD OF
ND24856OtherBLUE CROSS/BLUE SHIELD OF
ND23723OtherBLUE CROSS/BLUE SHIELD OF
ND355039Medicare PIN
ND489OtherBLUE CROSS/BLUE SHIELD OF
ND4981850001Medicare NSC
ND23723OtherBLUE CROSS/BLUE SHIELD OF