Provider Demographics
NPI:1265467526
Name:DIVINE PROVIDENCE HEALTH CENTER
Entity Type:Organization
Organization Name:DIVINE PROVIDENCE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-694-1414
Mailing Address - Street 1:312 E GEORGE ST
Mailing Address - Street 2:PO BOX 136
Mailing Address - City:IVANHOE
Mailing Address - State:MN
Mailing Address - Zip Code:56142-9707
Mailing Address - Country:US
Mailing Address - Phone:507-694-1414
Mailing Address - Fax:
Practice Address - Street 1:312 E GEORGE ST
Practice Address - Street 2:
Practice Address - City:IVANHOE
Practice Address - State:MN
Practice Address - Zip Code:56142-9707
Practice Address - Country:US
Practice Address - Phone:507-694-1414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331042275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24Z324Medicare Oscar/Certification