Provider Demographics
NPI:1336465038
Name:ST. JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH'S MEDICAL CENTER
Other - Org Name:ST. JOSEPH'S MEDICAL CENTER ANESTHESIA ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
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 1:14700 28TH AVE N
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4835
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:763-559-3791
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-829-2861
Practice Address - Fax:218-828-3103
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-20
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN347060207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05603Medicare PIN
MN240075Medicare Oscar/Certification