Provider Demographics
NPI:1336443225
Name:UPSIDE PSYCHIATRIC
Entity Type:Organization
Organization Name:UPSIDE PSYCHIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:TELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:218-766-5344
Mailing Address - Street 1:PO BOX 1795
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56619-1795
Mailing Address - Country:US
Mailing Address - Phone:218-766-5344
Mailing Address - Fax:
Practice Address - Street 1:1526 30TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4140
Practice Address - Country:US
Practice Address - Phone:218-751-0887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR127204-4261QM0850X
MNR1272044273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No273R00000XHospital UnitsPsychiatric Unit