Provider Demographics
NPI:1649223603
Name:ST. JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST. JOSEPH'S-PINE RIVER CLINIC
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 1:280 BARCLAY AVE W
Mailing Address - Street 2:
Mailing Address - City:PINE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56474-5197
Mailing Address - Country:US
Mailing Address - Phone:218-587-4416
Mailing Address - Fax:218-587-2677
Practice Address - Street 1:280 BARCLAY AVE W
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-5197
Practice Address - Country:US
Practice Address - Phone:218-587-4416
Practice Address - Fax:218-587-2677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330736261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN699019300Medicaid
MN699019300Medicaid