Provider Demographics
NPI:1457393035
Name:ST MARYS MEDICAL CENTER
Entity Type:Organization
Organization Name:ST MARYS MEDICAL CENTER
Other - Org Name:ESSENTIA HEALTH ST MARYS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:402 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1906
Mailing Address - Country:US
Mailing Address - Phone:218-786-4000
Mailing Address - Fax:
Practice Address - Street 1:402 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1906
Practice Address - Country:US
Practice Address - Phone:218-786-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331095282N00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457393035Medicaid
MN240002Medicare Oscar/Certification
MNC06029Medicare PIN