Provider Demographics
NPI:1902379159
Name:GRAND ITASCA CLINIC AND HOSPITAL
Entity Type:Organization
Organization Name:GRAND ITASCA CLINIC AND HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CLINIC SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACDONELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-999-1510
Mailing Address - Street 1:1601 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-999-1885
Mailing Address - Fax:218-999-1887
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-999-1885
Practice Address - Fax:218-999-1887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND ITASCA CLINIC & HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN288995200Medicaid