Provider Demographics
NPI:1558435131
Name:GRAND ITASCA CLINIC AND HOSPITAL
Entity Type:Organization
Organization Name:GRAND ITASCA CLINIC AND HOSPITAL
Other - Org Name:GRAND ITASCA CLINIC & HOSPITAL HC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TROUMBLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-999-1047
Mailing Address - Street 1:1601 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-999-1055
Mailing Address - Fax:218-999-1052
Practice Address - Street 1:111 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3663
Practice Address - Country:US
Practice Address - Phone:218-999-1055
Practice Address - Fax:218-999-1052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND ITASCA CLINIC AND HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN247286OtherIMCARE CLASSICS
MN59-00055OtherMEDICA
MN5B36AITOtherBCBS
MN885525100Medicaid
MN247286OtherUNICARE
MN885525100OtherIMCARE
MN247286OtherHUMANA GOLD CHOICE
MN59-00055OtherMEDICA