Provider Demographics
NPI:1417901000
Name:PRAIRIE ST JOHNS
Entity Type:Organization
Organization Name:PRAIRIE ST JOHNS
Other - Org Name:CHILDRENS PSYCHIATRIC HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EMMET
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENNEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:701-476-7882
Mailing Address - Street 1:510 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1914
Mailing Address - Country:US
Mailing Address - Phone:701-476-7200
Mailing Address - Fax:701-476-7261
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1914
Practice Address - Country:US
Practice Address - Phone:701-476-7200
Practice Address - Fax:701-476-7261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5063A283Q00000X
MN1567283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11778Medicaid
MN99725100Medicaid
MN099725100Medicaid
MN99725100Medicaid
MN099725100Medicaid
MNC03146Medicare UPIN
ND71130Medicare ID - Type Unspecified