Provider Demographics
NPI:1477509776
Name:ST. JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST. JOSEPH'S-CROSSLAKE CLINIC
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 1:35205 COUNTY ROAD 3
Mailing Address - Street 2:
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-4057
Mailing Address - Country:US
Mailing Address - Phone:218-692-1010
Mailing Address - Fax:218-692-1013
Practice Address - Street 1:35205 COUNTY ROAD 3
Practice Address - Street 2:
Practice Address - City:CROSSLAKE
Practice Address - State:MN
Practice Address - Zip Code:56442-4057
Practice Address - Country:US
Practice Address - Phone:218-692-1010
Practice Address - Fax:218-692-1013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330736261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN750027100Medicaid
MNC06015Medicare PIN