Provider Demographics
NPI:1013460864
Name:ST JOSEPHS AREA HEALTH SERVICES
Entity Type:Organization
Organization Name:ST JOSEPHS AREA HEALTH SERVICES
Other - Org Name:CHI ST JOSEPHS HEALTH ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-616-3500
Mailing Address - Street 1:4784 AMBER VALLEY PKWY S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8614
Mailing Address - Country:US
Mailing Address - Phone:701-237-8072
Mailing Address - Fax:
Practice Address - Street 1:600 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1431
Practice Address - Country:US
Practice Address - Phone:218-616-3700
Practice Address - Fax:218-616-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCE9455OtherRR MEDICARE
MNC05526Medicare PIN