Provider Demographics
NPI:1205043841
Name:PINE MEDICAL CENTER
Entity Type:Organization
Organization Name:PINE MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH SANDSTONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:705 LUNDORFF DRIVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072
Mailing Address - Country:US
Mailing Address - Phone:320-245-2212
Mailing Address - Fax:320-245-3251
Practice Address - Street 1:705 LUNDORFF DRIVE SOUTH
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072
Practice Address - Country:US
Practice Address - Phone:320-245-2212
Practice Address - Fax:320-245-3251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-16
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN361349275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1205043841Medicaid
MN24Z309Medicare Oscar/Certification