Provider Demographics
NPI:1740393032
Name:ST. JOSEPH'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH'S MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST. JOSEPH'S-LAKELAND PSYCHIATRY 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 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-828-7394
Mailing Address - Fax:218-828-3130
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-828-7394
Practice Address - Fax:218-828-3130
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-17
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330736261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN736045200Medicaid
MNC06015Medicare PIN