Provider Demographics
NPI:1225089634
Name:ST. MARY'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. MARY'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST. MARY'S HOSPICE & PALLIATIVE CARE
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 1:407 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2282
Mailing Address - Country:US
Mailing Address - Phone:218-786-4020
Mailing Address - Fax:218-786-4223
Practice Address - Street 1:407 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2282
Practice Address - Country:US
Practice Address - Phone:218-786-4020
Practice Address - Fax:218-786-4223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02562251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5025446OtherMEDICA
MN7L61STOtherBLUE CROSS BLUE SHIELD
WI1225089634Medicaid
MN1225089634Medicaid
MN1225089634Medicaid