Provider Demographics
NPI:1326041633
Name:PINE MEDICAL CENTER
Entity Type:Organization
Organization Name:PINE MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH SANDSTONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
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 1:705 LUNDORFF DRIVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072
Mailing Address - Country:US
Mailing Address - Phone:320-245-2212
Mailing Address - Fax:320-245-3251
Practice Address - Street 1:705 LUNDORFF DRIVE SOUTH
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072
Practice Address - Country:US
Practice Address - Phone:320-245-2212
Practice Address - Fax:320-245-3251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-31
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN361349282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1326041633Medicaid
MN22454NOOtherBCBS OF MINNESOTA ER
MN3945005OtherMEDICA ER
MN36F55PIOtherBCBS OF MINNESOTA UC
MN58444OtherHEALTH PARTNERS
MN01006123OtherPREFERRED ONE ER
MN1033994OtherPREFERRED ONE UC
WI1326041633Medicaid
MN6604104OtherMEDICA URGENT CARE
MNH109OtherUCARE ER
MN5013818OtherMEDICA UB
MNF793OtherUCARE UC
MN300142OtherUCARE AMBULANCE
MN3B24HPIOtherBCBS OF MINNESOTA UB
MN300142OtherUCARE AMBULANCE
MN3B24HPIOtherBCBS OF MINNESOTA UB