Provider Demographics
NPI:1184002347
Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Entity Type:Organization
Organization Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THEO
Authorized Official - Middle Name:A
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-584-7247
Mailing Address - Street 1:601 EAST ST N
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:ELGIN
Mailing Address - State:ND
Mailing Address - Zip Code:58533-7105
Mailing Address - Country:US
Mailing Address - Phone:701-584-2792
Mailing Address - Fax:701-584-3348
Practice Address - Street 1:601 EAST ST N
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:ND
Practice Address - Zip Code:58533-7105
Practice Address - Country:US
Practice Address - Phone:701-584-2792
Practice Address - Fax:701-584-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5014282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND35Z314OtherMEDICARE PTAN