Provider Demographics
NPI:1639648348
Name:ST JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST JOSEPH'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH LAKES IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:2019 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4528
Mailing Address - Country:US
Mailing Address - Phone:218-822-6736
Mailing Address - Fax:218-822-3758
Practice Address - Street 1:2019 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4528
Practice Address - Country:US
Practice Address - Phone:218-822-6736
Practice Address - Fax:218-822-3758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-26
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology