Provider Demographics
NPI:1649285172
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 1:417 FRANKLIN ST S
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1518
Mailing Address - Country:US
Mailing Address - Phone:320-634-4521
Mailing Address - Fax:320-634-2262
Practice Address - Street 1:417 FRANKLIN ST S
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1518
Practice Address - Country:US
Practice Address - Phone:320-634-4521
Practice Address - Fax:320-634-2262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN376010300Medicaid
243437Medicare ID - Type Unspecified
MNC02089Medicare ID - Type Unspecified