Provider Demographics
NPI:1588657696
Name:MONTICELLO-BIG LAKE COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:MONTICELLO-BIG LAKE COMMUNITY HOSPITAL
Other - Org Name:NEW RIVER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAWELK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-271-2306
Mailing Address - Street 1:1104 E RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8762
Mailing Address - Country:US
Mailing Address - Phone:763-295-5116
Mailing Address - Fax:
Practice Address - Street 1:1104 E RIVER ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8762
Practice Address - Country:US
Practice Address - Phone:763-295-5116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328129314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN053843400Medicaid
MN24Z362Medicare Oscar/Certification
MN245511Medicare ID - Type UnspecifiedMEDICARE PROVIDER N.H.