Provider Demographics
NPI:1235239229
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:701-786-1700
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:2006-09-22
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5010P282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
87726OtherMEDICA
ND1009Medicaid
ND489OtherBLUE CROSS BLUE SHIELD
01009717OtherPREFERED ONE
01009717OtherPREFERED ONE
87726OtherMEDICA
ND4981850001Medicare NSC