Provider Demographics
NPI:1346245446
Name:PHS MARANATHA INC.
Entity Type:Organization
Organization Name:PHS MARANATHA INC.
Other - Org Name:PHS MARANATHA INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:R
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6450
Mailing Address - Street 1:5401 69TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2684
Mailing Address - Country:US
Mailing Address - Phone:763-549-9600
Mailing Address - Fax:763-549-9636
Practice Address - Street 1:5409 69TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1505
Practice Address - Country:US
Practice Address - Phone:763-549-9600
Practice Address - Fax:763-549-9636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328432313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731342000Medicaid
MNNH0032OtherUCARE
MN245462Medicare Oscar/Certification