Provider Demographics
NPI:1275977928
Name:ST. MARY'S REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:ST. MARY'S REGIONAL HEALTH CENTER
Other - Org Name:ESSENTIA HEALTH ST. MARY'S - FRAZEE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-847-5611
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-334-7255
Mailing Address - Fax:
Practice Address - Street 1:300 MAIN AVE E
Practice Address - Street 2:
Practice Address - City:FRAZEE
Practice Address - State:MN
Practice Address - Zip Code:56544
Practice Address - Country:US
Practice Address - Phone:218-334-7255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-24
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN892442000Medicaid
MNC06026Medicare PIN