Provider Demographics
NPI:1609392992
Name:PHS INDIAN HOSPITAL
Entity Type:Organization
Organization Name:PHS INDIAN HOSPITAL
Other - Org Name:PHS INDIAN HOSPITAL-DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:THUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-3912
Mailing Address - Street 1:24760 HOSPITAL DRIVE
Mailing Address - Street 2:BOX 497 C/O BUSINESS OFFICE
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:PO BOX 497
Practice Address - Street 2:
Practice Address - City:REDLAKE
Practice Address - State:MN
Practice Address - Zip Code:56671-0497
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid