Provider Demographics
NPI:1255348223
Name:GLACIAL RIDGE HOSPITAL DISTRICT
Entity type:Organization
Organization Name:GLACIAL RIDGE HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:STENSRUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-634-2208
Mailing Address - Street 1:111 PLEASANT AVENUE
Mailing Address - Street 2:P.O. BOX 69
Mailing Address - City:BROOTEN
Mailing Address - State:MN
Mailing Address - Zip Code:56316
Mailing Address - Country:US
Mailing Address - Phone:320-346-2272
Mailing Address - Fax:320-346-2273
Practice Address - Street 1:111 PLEASANT AVENUE
Practice Address - Street 2:
Practice Address - City:BROOTEN
Practice Address - State:MN
Practice Address - Zip Code:56316
Practice Address - Country:US
Practice Address - Phone:320-346-2272
Practice Address - Fax:320-346-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN966011900Medicaid
MN966011900Medicaid
C02089Medicare ID - Type Unspecified