Provider Demographics
NPI:1376635151
Name:COOPERSTOWN MEDICAL CENTER
Entity Type:Organization
Organization Name:COOPERSTOWN MEDICAL CENTER
Other - Org Name:DAKOTA REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN ASSIST/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-786-1709
Mailing Address - Street 1:107 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-4501
Mailing Address - Country:US
Mailing Address - Phone:701-786-1700
Mailing Address - Fax:701-786-7121
Practice Address - Street 1:107 12TH ST S
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-4501
Practice Address - Country:US
Practice Address - Phone:701-786-1700
Practice Address - Fax:701-786-7121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOPERSTOWN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5001P275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2774OtherBLUE CROSS BLUE SHIELD
ND1912Medicaid
ND4981850001Medicare NSC
ND1912Medicaid
ND35Z306Medicare Oscar/Certification