Provider Demographics
NPI:1598902470
Name:MONTICELLO-BIG LAKE HOSPITAL
Entity Type:Organization
Organization Name:MONTICELLO-BIG LAKE HOSPITAL
Other - Org Name:NEW RIVER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FRIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-271-2303
Mailing Address - Street 1:1013 HART BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8575
Mailing Address - Country:US
Mailing Address - Phone:763-271-2306
Mailing Address - Fax:763-271-2421
Practice Address - Street 1:1013 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8575
Practice Address - Country:US
Practice Address - Phone:763-271-2306
Practice Address - Fax:763-271-2421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1598902470OtherMEDICARE OSCAR IP REHAB 24-R3262
MN155047100Medicaid
MN155047100Medicaid