Provider Demographics
NPI:1659455897
Name:ELY-BLOOMENSON COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:ELY-BLOOMENSON COMMUNITY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY HEALTH MANAGMENET OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-365-8765
Mailing Address - Street 1:328 W CONAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1145
Mailing Address - Country:US
Mailing Address - Phone:218-365-3271
Mailing Address - Fax:
Practice Address - Street 1:328 W CONAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1145
Practice Address - Country:US
Practice Address - Phone:218-365-3271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELY-BLOOMENSON COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN381970251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122747500Medicaid
MN122747500Medicaid