Provider Demographics
NPI:1962440362
Name:ESSENTIA HEALTH VIRGINIA, LLC
Entity Type:Organization
Organization Name:ESSENTIA HEALTH VIRGINIA, LLC
Other - Org Name:ESSENTIA HEALTH ELY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKCEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-2628
Mailing Address - Street 1:300 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:218-365-7900
Mailing Address - Fax:
Practice Address - Street 1:300 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:218-365-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMDC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-04
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1962440362Medicaid
MNC06442Medicare PIN
MN1962440362Medicaid
0440980001Medicare NSC