Provider Demographics
NPI:1548378474
Name:COOPERSTOWN MEDICAL CENTER
Entity Type:Organization
Organization Name:COOPERSTOWN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:BERTHIAUME
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:701-797-2128
Mailing Address - Street 1:1200 ROBERTS AVE NE
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-7101
Mailing Address - Country:US
Mailing Address - Phone:701-797-2128
Mailing Address - Fax:701-797-2457
Practice Address - Street 1:1200 ROBERTS AVE NE
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-7101
Practice Address - Country:US
Practice Address - Phone:701-797-2128
Practice Address - Fax:701-797-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34592282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME128180000Medicaid
ME128170000Medicaid
ME128180000Medicaid