Provider Demographics
NPI:1578781324
Name:HAZEN MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:HAZEN MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:SAKAKAWEA HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-748-7230
Mailing Address - Street 1:510 8TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4637
Mailing Address - Country:US
Mailing Address - Phone:701-748-7380
Mailing Address - Fax:
Practice Address - Street 1:510 8TH AVE NE
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4637
Practice Address - Country:US
Practice Address - Phone:701-748-7380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4053A251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59258Medicaid
ND357052Medicare ID - Type Unspecified