Provider Demographics
NPI:1851497309
Name:COUNTY OF ISANTI
Entity Type:Organization
Organization Name:COUNTY OF ISANTI
Other - Org Name:ISANTI COUNTY PUBLIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHS ADMINISTRATOR/ DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BUTTACAVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-689-8284
Mailing Address - Street 1:555 18TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008
Mailing Address - Country:US
Mailing Address - Phone:763-689-4071
Mailing Address - Fax:763-689-8293
Practice Address - Street 1:555 18TH AVE SW
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008
Practice Address - Country:US
Practice Address - Phone:763-689-4071
Practice Address - Fax:763-689-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1025957OtherPREFERRED ONE
MN8220ISOtherBLUE CROSS BLUE SHIELD
MN116467OtherUCARE
MN399853300Medicaid
MN8G633IFOtherBLUE CROSS BLUE SHIELD
MN8300061OtherMEDICA
MN8G633ISOtherBLUE CROSS BLUE SHIELD