Provider Demographics
NPI:1306832894
Name:SAWTOOTH MOUNTAIN CLINIC, INC.
Entity Type:Organization
Organization Name:SAWTOOTH MOUNTAIN CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-877-8263
Mailing Address - Street 1:513 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-3017
Mailing Address - Country:US
Mailing Address - Phone:218-387-2330
Mailing Address - Fax:218-387-1278
Practice Address - Street 1:513 5TH AVE W
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-3017
Practice Address - Country:US
Practice Address - Phone:218-387-2330
Practice Address - Fax:218-387-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN220211041C0700X
207Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN241806OtherMEDICARE/OSCAR CERTIFICATION
MN744708600Medicaid
MN844318100Medicaid
MN873397000Medicaid
MN536253900Medicaid
MN639097800Medicaid
MNBC69144COOtherGROUP CLAIMS-BCBS
MN4F029TEOtherDR. TERRILL-BCBS
MN785090500Medicaid